HomeMy Public PortalAbout5435 RYLAND AVE_Sewer__ WORKERS',COMPENSATION DECLARATION
Iti,hereby offiim"that ,1,have a certificate of consent to self
insure; or a certificate of Workers'Compensation Insurance, or 76A642D I
ra'certified copy thereof(See. 3800, Lab C.) 92-0002 DPW 6188 APPLICATION FOR PERMIT
Policy f4o. • Company
❑ pe'tified 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 = . a'+ r STATION DEPTH
COMPENSATION INSURANCE ADDRESS :, :< a0 .,. -J
This section need not be completed if the work involved b the �-� 9 UPPER
( p y LOCALITY a f-o f'�`.�9' ' (-1� - MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100)or IESS.) LENGTH FROM
1 certifythat in the NEAREST TYPE OF CONNECTION
performance of the work for which this CROSS ST y /+�` ` Y. CURB P.t 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.
y� � OWNER �C'ard(„' `��/i&�� CO.IMP.NO. JOB NO.
MAIL
Date'=� '�'' Applican �V6 'arr_ a_.P, _ ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO,
NO. DATE
NOTICE TO APPLICANT; If, after making This Certificate of CITY tet..No. AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR,
Exemption, you should become subject to the Workers' 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
LICENSED CONTRACTORS DECLARATION NO.of BLDGS. PERMIT No.
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 yy
effect. y _ CONTRAC OR �.s, G'-.�`J°3-�. may+ m ,, .+� CONNECTION CH'ARGE FEE
License Number i�l LiC Class y - . , a .�,,��1",tE d v - REIMBURSEMENT FEE 0
ADDRESS sy ! g f Y�-;ri-,
DISTRICT NO. GROUP MAP PROCESSED B' 7
DoteContractor(?',',t t ` - ✓Ll 'a j CITY TEL BK PG 0
�/... ,/�' STATE ,.,/ LIC. ,.-
❑ I am exempt under Sec. —of tfie L A.Co. LICENSE NO �r::3s CLASS i,!- _
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL W
HOUSE SEWER CONNECTING TOr VALIDATION tA3
B. $. P. Code for the following reason PUBLIC SEWER DATE?-p! ; Cn
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD -
Date, HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR y
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE
NFIELD
EN � pRYWL,MANHOLE
Low for the following reason (Section 7031.5, BUisness and Pro- ALTER.REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM --
❑ 1,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 safe (Section 7044, Business '
and Professions Code). OWNER'S Permit $
❑ 1,CIS owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE �^ j
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code). eCONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19—
for
9_for the performance of the work for which this permit is OWNER OR
issued (sec. 3097, Civ. C.). OWNERS AGENTADDRESS
Lender's Name
Lenders 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-mentlorjed roperty for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE