HomeMy Public PortalAbout5033 SANTA ANITA AVE_Sewer__ ' WORKERS'COMPENSATION DECI„RATION
r.I h6reby affirm that I have a certificate'.of consent to. self '4:
insure;,or a certificate of Workers'Compensation Insurance, or ' 9ansezo
a certifiQQropy'thereof,(SLc-,1STLab C.) 92.-0002 DPW 1318.8 ® 1
Policy Company- i. EtaI�.A�I®�t ff' fl� IT PERM
.❑.Certified.copy 1s hereby furnished.. ���� SEWAGE: DISPOSAL
figol5r—ified.copy is filed with the C; in irispection COUNTY OF;IS ANGELES �, BUILDING AND$AFETY
deperfinent:..
Dat. 3- .Applicant -'FOR NTT. FILL ON CONNECTION DATA
CERTIFICATE'OF EXEMPTION FROM WORKERS'
BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRISS
(This section need not be completed if the work involved by the j ; MANHOLE REFERENCE UPPER
permit is for one hundred dollars($'100)or less.) : LOCALITY LOWER
1 certify_ that. in the `performance .of the work for which this NEAREST ' TYPE.OF.`CONNECTION LENGTH FROM _
,' .CRO555T.. - •, Y'._ .CURB. P.L� MA:TO P•l:
permit is issued; I:shall not.employ any person in.any manner P.C.N.O.
so.as.to become subject to the Workers'Compensation Laws. OWNER n CO.'IMP.W. JOB.NO;
•MAIL + TRUNK PERMIT NO. ROAD PERMIT NO.
Dote � Applii:arir' " Ij ADDRESS 0�� . � � i' "
NOTICE TO APPLICANT: If, after making. this Certificate of !,CITY 11 AFFIDAVITWAIVER •EASEMENT 'RECORD.IN5IR..NO. DATE
Exemption, you should become subject to the 'Workers' TEL:NO, ['I
Compensation provisions of the Labor code;you must forthwithDeSLEG 1LION LOT No. 1:I FI11VY,OR SL;WIDENING
comply with such.,provisions or this permit shall be deemed
revoked. BLOCK. TRACT STATE.ENCROACHMENT
"•
LICENSED CONTRACTORS DECLARATION NO.of BLDG PERMIT NO.
NO
SIZE OF LOT NOW ON LOT
1 hereby affirm that.1 am licensed under,provisions of Chapter +'
9 (commencing ) SE OF
with Section 7.000' of,Division 3 of'.the.Busi- ;:euiIDINGs CHARGES'.
Hess and Professions Code, and my license is,in full force and C y,
i'
effect. '� r �' CONNECTION CHARGE.FEE
„CONTRACTOR
License Number 3 LIC.Class C— kADDRE�S sxi. �. REIMBURSEMENT FEE
DISTRICT NO" GROUP 'MAP PROCESSED BY
Contracto Date :fid " ' /� /i .
CITY CA llrT TEL.NO.% S: PG
❑1 am exempt under Sec. of the L:A.Co. ;, �ENS� — CA r iT r�
NO. DESCRIPTION.OFWORK� N. FEE
Plulnb)ng,Codeand/or'Sec. of the FINAL ger rp��
HOUSE.SEWER GONNECTING70' , ;.DATE 1' ALIDATIO.N VJ
B. &P. Code for the following reason o PUBIICSEINER 4 ,yy �a—
SEPTI.C'TANK.SEEPAGE%'T OR FINAL i ►i '!a.4
PITS AND/OR DRAIWFIELD
Date I. . WOUSE_SEWER CONNECTING TO BY
_ PRIVATE DISP.OSASYSTEM
' '_ a� i �•i: t5640
Sign tvZGfo e�7��-p' -� CONNECT ADDITIONAL BLDG_:OR
WORK TO HOUSE.SEWER
OWNER-BUILDER DECLARATION
OVERFLOW SEEPAGE..PIT,DRAI.NFIELD (� _ 2,
1 hereby.offirm.:that I:am exempt from the Contractor's License' EXTN..CESSPOOL DRYWELL,MANHOLE., .. y #s�A' ��
Law'for,the following reason (Secton:7031..5;._Buliness'and'Pro- r' ALTER;REPAIR OR ABANDON NDON HOUSE (' a.
fessionsCode): SEWER OR DISPOSAL,SYSTEM: +' lty
CKICK Stu a l L
❑ 1,as owner of the property,or my employees with wages as
their sole.compensatiop,will do the work and the structure
is not intended:or offered for sale(Section 7044, Business ti
and Professions Code). OWNER'S Perrhit'�( $.
❑ 1,as owner of the property-,am exclusive) contracting with AUTHORIZATION I / �i U-100011 10jf 3/9.1;
P P Y Y 9 TOTAL.PEE •� / -yI�•
licensed contractors to.construct the;project (Section 704.4, 1 HAVE:..AT THIS DATE A CONTRACT.WI.TII{{THE HEREIN NAMED CONTRACTOR TO rO' ar+
Business and Professtoiis'Code;). CONNECT THE!ABOVE DESCRIBED EXISTING DWELLING TO THE PyBlICSEWER: •?�• 1 AM. _001
CONSTRUCTION LENDING AGENCY
1 hereby affirm that 'there is a construction lending agency ' SIGNEDTHIS DAYOF 19_
OWNER OR
for the performance of the work-for which. this permit .is I 1 ,
OWNERS AGENT'
issued (Sec.'30Q7,Civ' . C.). ADDRESS '
Lenders.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 I
ordinances and State laws regulating Plumbing and-Sewers, "
and hereby authorize represent !Ives of this County to enter
upon.the above=the, t!o ed pert for inspection purposes.. yj t
I'
1 1
Signature of Permittee Date. SEE REVERSE FOR EXPLAWATORY,LANGUAGE ' i