HomeMy Public PortalAbout5929 ROWLAND AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
1 herebw affirm that ].have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insuranc�I or /6A6420 LS
a�certified co thereof Sec. 3800,.Wb�C. "��t ji CE 808(REV-8 81
copy ( l APPLICATION FOR PERMIT
Polic o. Company
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 FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDREss lt3!� sTAnoN DEPTH
(This section need.not be completed if the work involved by thi? LOCALITY` c--,,- �i {,,.� '�} MANHOLE REFERENCE UPPER
LOWER
permit is for one hundred dollars ($100)or less.) +
NEAREST - TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CRoss sr. ✓ `�� Y, CURB P.I, M.L.TO P.L.
permit is issued, I shall not employ any person in any manner P C.NO,
so as to become subject to the Workers' Compensation Laws. OWNER f_5 K \k,02—C CO.IMP.NO. JOB NO.
MAIL
Date _Applicant ADDRESS_ TRUNK PERMIT NO. ROAD PERMIT N0.
NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO, DATE
CITY TEL.NO.
Exemption, you should become subject to the Workers' LEGAL
JJ'��,
Compensation provisions of the Labor code, you must forthwith DESCR PTION LOT NO. —0 HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT 61�_,/py
STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION r NO.of BLDGs. PERMIT No.
SIZE OF LOT !i( �tJ 4f NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE of
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS c,,`a'I 4,L 0'%!at L L-- CHARGES
ness and Professions Code, and my license is in full force and A
effect. }r?� + 11.� CONTRACTOR ��—[g,�r t; yy/3'1 `„�( f y� CONNECTION CHARGE FEE CL
_
License Number l Lic.Class L� ADDRESS sGl� {�> ' REIMBURSEMENT FEE O
�,j DISTRICT NO. GROUP MAP �CESSED BY
Contractor l �`�/ Date CITY `' }� TEL.NO o 0 /� tiZ
115-1 ILI /� o
❑ 1 am exempt under Sec. of the L.A.Co, STATE No. LIC, ' ✓
eK PG
Na DESCRIPTION OF WORK FEE 1 U
Plumbing Code and/or Sec. of the FINAL W
HOUSE SEWER CONNECTING TO DATE "/'
PUBLIC SEWER 7 VALIDATION
-- jy,
B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FIN Z
PITS AND,OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM r --
Signature CONNECT ADDITIONAL BLDG.OR 1 /
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE r
Law for the following reason (Sectors 7031.5, Buisness and Pro- ALTER.REPAIR OR ABANDON HOUSE rG (7� h A
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ I, as owner of the property,or my employees with wages as �' ! Q
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit _ $ t f a l
❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT
ADDRESS
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
upon thea �e tioned property f 'r 'Itionpurposes.
S ature df Permittee atl7 a SEE REVERSE FOR EXPLANATORY LANGUAGE