HomeMy Public PortalAbout5123 SANTA ANITA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
1'hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C.) CE908(REV.B/BT) APPLICATION FOR PERMIT
Policy No. _Company '?l$
❑ 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.
Date Applicant FOR APPLICANT TO FILL IN CONN ECTIW DATA _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ABUOIDLDREINsG J1
23 xd,,Y',ff7 AN/r/ 14V,:5-
(This
4 r(This STATION r EPTH
section need not be completed if the work involved by the LOCALITY /C-.rs� MANHOLE REFERENCE ,�.
permit is for one hundred dollars ($100)or less.)
NEAREST TYPE OF CONNECTION 6.r"' LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. F\ Y. CURB / PA M.L.TO P.L.
permit is issued, I shall not emloy any person in any manner //1 � v
so as to become subject to the s"Compensation Laws. GWNER uli.' f /\ /V CO.IMP NO. JOB NO
MAILTRUNK PERMIT NO. ROAD PERMIT NO.
/Date Applicant — ADDRESS -crj/23 S1 7—h 1U� TA ,V&—
.�" �7 C AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY 6?rlgee�G!, TEL.NO
Exemption, you should became subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
NO.OF BLDG$, 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
effect. CONTRACTOR �' CONNECTION CHARGE FEE
License Number Lic.Class _ --` REIMBURSEMENT FEE 0
ADDRESS _ O-
Contractor DateCITY (1, TEL.NO. DISTRICT NO. GROUP MAP PROCESSED B3Y U
,i BK PG Z
❑ I am exempt under Sec. of the L.A.Co. LICENSE No,
LIC,
NO, DESCRIPTION OF WORK E `j
Plumbing CodeandiorSec. of the
HOUSE SEWER CONNECTING 70 DFINAL 4
ATE VALIDATION
PUBLIC SEWER ,r�
B. 8 P. Code for the following reason Z
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY _
PRIVATE DISPOSAL SYSTEMillhlml /27\
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD Awl VON
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE 00.
Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE '
Jess, s Ca de - SEWER OR DISPOSAL SYSTEM -
} LYJ I,as owner of the property,or my employees with wages as ACICT.1
1 their sole compensation, will do the work and the structure7 �27�
is not intended or offered for sale (Section 7044, Business 3 .9.0
and Professions Code). OWNERS Permit $ /} 1 ITEMS
❑ I,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 ACO RACT WITH THE HEREIN NAMED C" TRACTOR TO TOTAL 27. 50
Business and Professions Code). CONNECT THE ABOVE DESCRIB EXISTING DWELLING TO THE PUBLIC SEWER. „� �,�
CONSTRUCTION LENDING AGENCY f +f �r1 she ■53
I hereby affirm that there is a construction lending agency SIGNED THIS F Z[ C' I CH t
for the performance of the work for which this permit is OWNERa RGENr
issued (Sec. 3097, Civ. C.). ADDRESS ✓'�� ,, `ivt7� 6/--,1 ,�+�`
Lender's Name '3000-0001 6/16/29
Lender's Address 4017 1 1M 9:(1 ,
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordin ces and State laws regulating Plumbing and Sewers,
reby authorize representatives of this County to enter
up e ove-mentioned property for inspecti n purposes.
Signature of Permittee D e SEE REVERSE FOR EXPLANATORY LANGUAGE