HomeMy Public PortalAbout5937 ROWLAND AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
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I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or �eAba2o
a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV-8,81APPLICATION FOR PERMIT
Policy No. Company his
El Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
dep
Date ' Applicant %f"�'=1' i `A11.11 CONNECTION DATA
ar FOR APPLICANT TO FILL IN
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING 'c STATION DEP
COMPENSATION INSURANCE
ADDRESS '�, F� ®`�
(This section need not be completed if the work involved by the MANHOLE REFERENCEUPPER
c's°'f ,/,r' �-'� WER
permit is for one hundred dollars ($100)or less.) LOCALITY
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I certify that in the performance of the work for which this NEAREST CROSS ST. TYPE OF C LENGTH FROM
Y. URB P.L. M.L.TO P.L. �-
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers"Compensation Laws. OWNER P.C.No.
�9 .�") rd, � ��z'�t}' CO.IMP.NO. JOB NO. Q
�t�,F� r8-^✓ " ,x .¢'Y` MAIL
F,s��^e�✓�m�'� °' f .,� ADDRESS 9m"" TRUNK PERMIT NO. ROAD PERMIT NO. �s
Dote��—Applicant 0
AFFIDAVIT WAIVER EASEMENT RECORD.lNSTR.NO. DATE `�
NOTICE - O APPLICANT: If, after making this Certificate of CITY *`r` TEL.No
Exemption, you should become subject to the Workers' V
LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed !_
revoked. BLOCK TRACT STATE ENCROACHMENT z
LICENSED CONTRACTORS DECLARATION No.OF BLDGS. PERMIT No.
SIZE OF LOT NOW ON LOT '- F• '
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 sD` CHA
ne.ss and Professions Code, and my license is in full force and a
effect. CONTRACTOR
CONNECTION CHARGE FEE
License Number Lic.Class ADDRESS r' 'r,; J;- ,. _ � RE,MBURSEMENT FEE
s , _
,r- �;�.� ,arr '� ^'^f+' „ F"” D'.STRICf NO. GROUP MAP LA
BY
Contractor Date "' CITY ,� '4
,. ,.�° f TEL.NO. Q' BK PG
❑ I am exempt under Sec, of the L.A.Co. LICENSE NO. �TATEw 4 CLASS "�
NO. DESCRIPTION OF WORK FEE
Plumbing Cade and/Or Sec. of the HOUSE SEWER CONNECTING TO DATE r .T r.. VALIDATION
PUBLIC SEWER
B. & P. Cade for the following reason SEPTIC TANK, FINAL SEEPAGE PIT OR C
PITS AND"OR DRAiNFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM -
Signature = CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD ` &
1 hereby affirm that I am exempt from the Contractor's License EXTN,CESSPOOL,DRYWELt,MANHOLE
Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code):
SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as
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 S �
I, os 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 ON RACTOR 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 i9_
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 law&-4egulating Plumbing and Sewers,
and hereby out Br e
rae sentatives of this County to enter
upon the-gkt6V.-I pro for inspection purposes.
nSignature of Pern'iiitee DaM f` SEE REVERSE FOR EXPLANATORY LANGUAGE