HomeMy Public PortalAbout6008 ROWLAND AVE_Sewer__ WORKERS' COMPENSATION DECLARATION c�
1 'h f4iTy If , this;! I have a certificate of consent to. self 200057 OPW 689 u
s ns,:'cs or ceerrrtiflcate of Workers' Compensation Insurance, or 76A6A2p
Sa c°erlitied �c_VA1 f (Sec 3800; � APPLICATION FOR PERMIT
PI cy No._3L7�` ��r ompany .
Cr;rnfied copy Is hereby furnished sf e)? SEWER. - SEWAGE DISPOSAL
Certified copy is filed with The county Iding .inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
de ortmenr
/� r �
DcteV. 7Applicanr ??�_ _ FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM.WORKERS` BUILDING ( - t
COMPENSATION INSURANCE ADDRESS m. 1 STATION �_ l�,' DEPTH
u E
(This section one not re completed If thework involved by the LOCALITI' a -!r MANHOiF REFERENCE �' :�,{ LOWS
permit is for one hundred dollars ($100)or less ) �'-�`sre�- c't.. �.-
NEAREST TYPE OF CONNE�TiON LENGTH FROM
certify that in the performance of the work for which this CROSS ST, y P L Ml, TO P L A? F
permit is issued, I shall not employ any person in any mariner LEGAL PC No
o as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO CO IMP NO JOB NO
Dote_ Applicant,_. BLOCK TRACT TRaNK.PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, after mgkin ih i5 CerlifiCafe Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
g MAP BOOKPAGE PARCEL
Esempti'on, you should become subject to the Workers'
::Orn ensation rovis,ons of the Labor code, you must forthwith No of BLOcs
- p p y�� SIZE OP LOT NOW ON LOT HWY OR ST WIDENING -
c,rnply with such provisions or this permit shall be deemed USE OF
revoked. 18LJIL_D,NGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT No
hereby affirm that I am licensed under provisions of Chapter OWNER �e
9 y
(commencing with Section 7000) of Division 3 of the Bwsi- MAIL r
ADDRESS
I�f `• C CHARGES
-,ess and Professions Code, and mV license is in tut,' force and
/.� K y YNECTION CHARGE FEE
,.
effect. CITY c� 4l5 1 v.,:L.J tV TEL.NO_ Z ` ��G CO
l
LicenseNumber - _LIC. Class r—,a .__ REIMBURSEMENT FEE
CONTRACTOR ��((� � DISTRICT NO GROUP MAP PROCESSED BY
Contractor_!' Date �C1 a P..
ADDRESS '�l ��. ttl-.�! � 4 BK PG
I am exempt under Sec. of the L.A.Co. rj �[ 7 �. �' r L � � _- ,R • K: - ,` Q
CITY (.�.- f" - TEL NO. �7-'�[.a Q
Plumbing Code and/or Sec of the STATEuc F ,AL 0
LICENSE NO. '7 rGLA51�.' ..�. D?.TE VALIDATION
B. 8 P. Code for the- following reason NO. DESCRIPTION OF WORK FEE 0
HOUSE SEWER CONNECTING TO ! R.•^`,,. FINAL
Date PU8 SEWER
SEPTIC TANK SEEPAGE PiT OR • d
Signature PITS AND OR DII INFIEID Pl7
OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING TOPR VATE DISI SYSTEM Pilo.I hereby affirm that I am exempt from the Contractor's License >NNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER 4-M'
f E, .VERFLOW SEEPAGE"T DRAWFIEID
SSiOnS Code): EXTN.CESSPOOL.DRYW'ELt..MANHOLE
•. i u'�`
L� 1, as owner pert of the of employees with wages as ALTER REPAIR OR ABANDON HOUSE a _
property,Y, Or m Y Y g _EWER OR MSPOSAI.`SYSTEM
their sole crmpenso?ion, will do the work and the structure
is not intended or offered for sale (Section 7044, Business a T'i"*
and Professions Code) i ,., "`
C_I I, as owner of the property, am exclusively contracting with t t i i.. 66 o so 11,
licensed contractors to construct the project (Section 7044, OWNER'S Permit $ yt fd
Business and Professions Code). AUTHORIZATION TOTAL FEE '� ' `EC
CONSTRUCTION LENDING AGENCY HAVE AT THIS ATF A CONTRACT WITH THF -411 NAME ONTRA[TOR T
I hereby affirm that there is a construction lending agency CONNE.-T 7HE ABC)VE DFSCQiEIED EXISTING ONEUING TO THE PuBi ^SEWER
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C ) SIGNED THIS DAA'OF Iq�
x.
Lender's Name OWNERS AGENT
.— _- ',a°
Lender's Address__..-----_-- ADDRESS �._ — -— — -- --- - '
I certify that I have read this appliCCl ion and stare that the ..
above information is correct. I agree to comply with all County
ordinances and State lawsregulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
Upon the abov tiCne roperry for inspection purposes.
Signature of Permittee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE