HomeMy Public PortalAbout5730 RIO HONDO AVE_Sewer__ (
WORKERS'COMPENSATION DECLARATION
a affirm that I have a certificate of consent to self
Insu.e, or a certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C.) CE e0e(REV.a/el) APPLICATION FOR PERMIT
Policy No. Company_ Cris
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant _ FOR APPLICANT TO FI91LINCONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' aLINING
COMPENSATION INSURANCE ADDRESS TION : DEPTH
(This section need not be completed if the work involved by the NHOLE REFERENCEpermit is for one hundred dollars ($100)or less.) LOCALITY {�(' . ,1 7J LOWER'NEAREST f TYPE OF CO T NI certify that in the performance of the work for which this CRoss sT. "v V CURB` P.L. M.L.TO P.L.
permit is issued, 1 shall not employ any person in any mannerP, B NO.
so as to become subject to the Workers' Compensation Laws. OWNER i '( 7 IMP.NO. JOB NO.
�/� ,�} MAIL " NK PERMIT NO ROAD PERMIT NODate..3-(Applicant ADDRESS 3 0 '3NOTICE TO APPLICANT: If, after makin this Certificate of vAFFIDAYIi WAIVER EASEMENT RECORD.INSTR.NO. BATE
g CITY �� ;� TEL.NO. JExemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. Y.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACTTE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDMIT NO.stZE OF LOT NOW ON LO /
I hereby affirm that I am licensed under provisions of Chapter . ^"
USE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS0,,` "' CHARGES a% c
ness and Professions Code, and my license is in full farce and
effect CONTRACTOR CONNECTION CHARGE FEE �.
EL
License Number Lic.Class_ ADDRESS REIMBURSEMENT FEE O
Contractor Date DISTRICT NO GROUP MAP PROCESSED BY u
CITY TEL.NO. 1� ,� BK PG �, I z
El am exempt under Sec. of the L.A.Co. CENSE NO.STACLASS �' 4 O
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Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE HNAt U
HOUSE SEWER CONNECTING TO • "� /V � DATE /l - VALIDATION n.
PUBLIC SEWER / L
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR / Z
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY ! .(
PRIVATE DISPOSAL SYSTEM
Signature _ CONNECT ADDITIONAL BLDG.OR / t, "p 11, ti
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER 6 1 1'1
r�
I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN,CESSPOOL,DRYWELL,MANHOLE a a a • iJ
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
AI,as owner of the property,or my employees with wages as e ® 7 ,`� `5
their sole compensation, will do the work and the structure L J a
is not intended or offered for sale (Section 7044, Business O ): %'`87
❑ and Professions Code). OWNER'S Permit 1CONTRACTOR
I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEElicensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIBusiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TCONSTRUCTION LENDING AGENCYI hereby affirm that there is a construction lending agency SIGNED THISDAY OF
for the performance of the work for which this permit is OWNER OR
sued (SBC. 3097, Civ. C.). OWNERS AGENTADDRESS
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and here!4y author' representatives of this County to enter
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oned property for ins ecti purposes.
3 V ': i-
ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE