HomeMy Public PortalAbout4836 RYLAND AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
1 hereby. affirm D
Yhat I have a certificate of consent to self 76A642 DPw a/8�
'inSCE ure` or a certificate of Workers'Compensation Insurance, or PM
a certified copy thereof (Sec. 3800, Lab C.) �E B� APPLICATION FOR PERMIT
Policy No. Company is
❑ 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. --
Gate Applicant FADrRE
APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' STATION DEPTH
COMPENSATION INSURANCE(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100) or less.) LOWER
I certif that in the erformance thework rwhichthis TYPE OF CONNECTION LENGTH FROM
Y P Y. CURB P.L. M.L.TO P,L.
permit is issued, I shall not employ a per, many manner
so as to become subject to th "Work ensation Laws. P.c.No.
�" C+ . OWNER CO.IMP.NO. JOB NO.
,r+' --.•""`a...,...... MAIL
'� ``� �.+✓" ADDRESS TRUNK PERMIT NO. ROAD PERMR NO.
Date 3 9 UAppIIcant 1--R4LAND AVENUE
NOTICE TO APPLICANT: If, of i making this Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR NO, DATE
9 CITY EL NO.
Exemption, you should e subject to the Workers' L —
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
NO.OF BLDGS. PERMIT NO.
LICENSED CONTRACTORS DECLARATION SIZE OF LOT 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 CHARGES
ness and Professions Code, and my license is in full force and BUSY
effect. CONTRACTOR BUJ t BEE PLUMBING CONNECTION CHARGE FEE
License Number 418394 Lic.Class C B ADDRESS REIMBURSEMENT FEE o
DISTRICT NO. GROUP MAP PROCESSED BY 0
Contractor R I I C x BEE Date 1T�T9� CITY TEL.NO. Z
BK PG
El am exempt under Sec. of the L.A.Co. STATE LIC. 't 0 U
P LICENSE NO. CLASS /� I
Plumbing Code and/or Sec. of the NO. I DESCRIPTION OF WORK FEEFINAL U
HOUSE SEWED.CONNECTING TO DATE VALIDATION W
PUBLIC SEWER d
B. & P. Code for the foraying reason SEPTIC TANK,SEEPAGE PIT OR i 0
// PITS AND/OR DRAINFIELD FINAL
s Date HOUSE SEWER CONNECTING TO BY
g/ ! PRIVATE DISPOSAL SYSTEM
Signature R. CQL�LIEG.LADOuaL st, .OR ,
ER-BUILD ECLARATION r�voRK TO HousE sewER .1y G}t
`DRAINFIELD
1 hereby affirm that I am exempt from the Contractor's License I EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law 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 $.C57 C/
❑ 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 A
P p OWNERS AGENT
issued (Sec. 3097, Civ. C.). 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 the above-mentioned property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE