HomeMy Public PortalAbout5822 ROWLAND AVE_Sewer__ WORKERS'COMPENSATION DECLARATION 76A6420 APPLICATION FOR PERMIT
CE 808 (2$0)
I hereby affirm that I have a certificate of consent to self SEWER—SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY
a certified copy thereof(Sec. 3$00, ab. C _
Policy No. Company ;��/°'���` 'l, L' 'F'! �� ,�-I'tl.��;°. ,I"G i,�^ />f'i_
FOR APPLICANT TO FILL IN CONNECTION DATA
Certified copy is hereby furnished. L f
BUILDING ,.{,,� ,y� �� yJ )3 STATION '' ' DEPTN 4,y,
ADDRESS `i---./1✓ 1'r_S.` 9iITr."�. ! O UPPER
-mortified copy is filed withZt �county buil Ing inspectionANHOLE REF R CE fy /) t� M E (x,N IG+de?art nt. / LOCALIT�'� � �y>� £ � � �w.y, „ ,�,:�.� ' 7YPE OF TIONLENGTH FROM
DateApplicants -<f z s- NEAREST p � y� 4 a}.�`� Y. cUR
CROSS ST. is P.L. M.L. TO P.L.
CERTIFICATE;OFEXEMPTION hEMPTION FROM WORKERS' P.C. NO.
COMPENSATION INSURANCE OWNER , 'R. a co. IMP. No. JOB No. y�
MAIL TRUNK PERMIT NO. ROAD PERMIT NO. , � /7
(This section need not be completed if the work involved ADDRESS 0'
by the permit is for one hundred dollars ($100) or less.) AFFIDAVIT WMVER EA.4EMENT RECORD. INSTR.NO. GATE
CITY TEL. NO. U
I certify that in the performance of the work for which this LEGALL”permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. y}l 3 HWY. OR ST. WIDENING
so as to become subject to the Workers' Compensation haws. STATE ENCROACHMENT
BLOCK TRACT PERMIT NO. �tLU
Date Applicant NO. OF BLD GS. s ,
SIZE OF LOT NOW ON LOT (�
NOTICE TO APPLICANT: If, after making this Certificate of USE of CHARGES
Exemption, youshould should become subject to the Workers' BUILDINGS
Compensation provisions of the Labor Code, you must forth- �1yy _tea CONNECTION CHARGE FEE
with complywithsuch 'provisionsor this permit shall be CONTRACTOR r' a',ht 0"✓" /'/ '�°r`"+tLn'"l
deemed revoked. REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS �'� �'S �"�t3»� /� ''t J+f.��' °i
_ DISTRICT NO. GROUP MAP PRO ESSED BY
I hereby affirm that I am licensed under provisions of Chapter CITY idrl�' r TEL. NO. "I S- q �`
BK PG
9 (commencing with Section 7000) of Division 3 of the Busi- STATE LIC.SS
ness and Professions Code, and my license is in full force and y ' -
LICENSE NO F � / CLASS
effect. NO. DESCRIPTION OF WORK FEE FINAL C'� 2 c r VALIDATION
HOUSE SEWER CONNECTING TO
"' ✓..� LIC.Class
PUBLIC SEWER ,J r DATE
License Number-XS -
y� `p J SEPTIC TANK,SEEPAGE PIT OR
/V ^` VI ,V'• )n�°E' '�'�wK•. ,-,�_Rs./ PITS AN DIOR DRAINFIELD FINAL I
, :� VI aK• K7 .oF
anti (. or �.r ate HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
I am exempt from the licensing requirements as I am a
CONNECT ADDITIONAL BLDG.OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
C OVERFLOW SEEPAGE PIT,DRAINFIELD
acting in my professional capacity (Section 7051, Bus- EXTN.,CESSPOOL,DRYWELL,MANHOI r
Code). :5
iness and Professions Code). ALTER,REPAIR OR ABANDON HOUSE
OR OI SPOSAL SYSTEM
Hc.or Reg.No.2 S -3 3' Date dfi i
HOME OWNER-BUILDER DECLARATION
OWNER'S Permit s
I hereby affirm that I am exempt from the Contractor's AUTHORIZATION TOTAL FEE
license Law for then following reason (Section 7031.5, Busi-
ness and Professions Code): 1 HAVE AT THIS DATE A CONTRACT WITH THE: HER Ei1N NAM EO CON-
IRACTOR TO CONNECT THE ABOVE DESCRIBED £XISTInG DWELLiMG
1, as owner of the property, will do the work and the TO THF. PUBLIC SEWER.
Structure is not intended or offered for sale (Section SIGrTED THIS DAY OF t9-
7044, Business and Professions Code). OWNER OR
OWNERS AGENT
CONSTRUCTION LENDING AGENCY ADOREss ---
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
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 hereby authorize representatives of this County to enter
Lipo the abofver me �ncil74e-�1!!property for inspection purposejs�. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date