HomeMy Public PortalAbout5560 ROBINHOOD AVE_Sewer__ WORKERS' COMPENSATION DECLARATION C�
I hereby Affirm that I have a certificate of consent to self 20-0031 DPW ISM u
inure, or a certifTcate�of Workers'Compensation Insurance, or 75ABAZD
a certified copy thereof rSec. 3800, Lab C.) APPLICATION FOR PERMIT
Policy No. Company
Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
El
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.. r. 0;
DQte Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIKICA7E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ADOFM SS 6 Q ✓ STATION DEPTH
(This section need not be completed if the work Involved by the MANHOLE REFERENCE _UPPER
permit is for one hundred dollars ($100) or less.) LOCA)JTY
NEAOM
I certify that in the performance of the work for which this FIM TYPE co"A'ROT M L TO P L
d � v�.. Y CURB PL ML TOPL
permit I$ issued, 1 shall not employ any person In any manner LEOAi PC NO
so as to become sub(ect to the Workers' Cbmpenwtion Laws. DEBCEYPTION LOT NO. CO uv NO 1081 NO
Date Applicant BLOCK TRACT TRUNX PERMIT NO ROAD PERMIT NO
NOTICE 70 APPLICANT: If, after making this Certificate of '�BaoR AFFDAVIr WATVER EASEMENT RECORD INSTR NO DATE
9 YAP BOOK PAGE PARCEL
Exqmption, you should become subject to the Workers'
No.OF EtLDG&
Compensation provisions of the Labor code, you must forthwith BEZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BLA L DI NGB STATE D 40K AC`MENT
LICENSED CONTRACTORS DECLARATIONPERhvT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- A DRI $ O aiARGEs
ness and Professions Code, and my license Is In full force and O
effect. CTYTEL No.d — — CONNECTION CHARGE FEE
License Number Lic.Class WLMBU NT
GONTRACTOFI
Contractor Date FEA
DISTRICT NO GROUP MAI' M
ADDRE$B � � 6X PG
E] I am exempt under Sec, of the L.A-Co.. & rAi
CITY TEL Q VALIDATI 1X 2!
^
Plumbing Code and/or Sec. of the NATE LIC �Z d
LICENSE NO. GLASS DATE Jl
B. 8 P. Code for the following reason Na DAMN 0P WORK FEE FQ
Date PUBLIC SrIYEAP CONNECTING TO BYAl yyyVJJJ
StKK TANK SEEPAGE PIT OR
Signature PITS AND OR DRAINFQ:W
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TING To ,
PRNA DI
I hereby affirm that I am exempt from the Contractor's License CONNECT ADLHrION AI BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK To HCQM SEWER
fessions Code): OVERFLOW SEEPAGE PTT.DRAINFIELD
EXTN.CESSPOOL.DRYWELL MANHOLE
C91, as owner of the property, or my employees with wages as ALTER. REPAItt OR ABANDON HCUS.E
their sole compensation, w71 do the work and the structure SEWER OR DLSPO,SAL SYSTEM Iii
is not intended or offered for sole (Section 7041, Business �C� +
and Professions Code). 'T
❑ I, as owner of the property, am exclusively contracting with Permit �.} 55.35
licensed contractors to construct the project (Section 70", OWNER'S
Business and Professions Code). AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE FRREIN NAMED CONTRACTOR TO l TOTAL. 55- 35
1 hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER }-� �'�
for the performance of the work for which this permit is ��•J.!■`.F�-'
issued (Sec. 3097, Civ. C.). SlGNED TF{IS. DAY OF 19_ 1 PM 41 r�
OWNER OR ■EJV
Lender's Name OWNERS AGENT
Lender's Address ADOREss
I certify that I have read this application and state that the OOOCKM1 7f 7/94
above information is correct. I agree to comply with all County 5 �
ordinances and State laws regulating Plumbing and Sewers,
4-6
and hereby authorize representatives of this County to enter
upon the above- ntioned prop"
c�for Inspection purposes.
Signature ( Date SEE REVERSE FOR EXPLANATORY LANGUAG!