HomeMy Public PortalAbout5323-5325 SANTA ANITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificot of consent to self 76A64t DPW 6189
insure, or a certificate of Worrker9� m r1sation Insurance or ?fiA642D �. ,
a certifie There e N00 K, C ) f � ;� y
Po cy Nat.—_..—� ny �����1. APPLICATION
-FOR PERMIT
-.certified copy .s hereby furnished SEWER • SEWAGE DISPOSAL
(_] Certified copy is filed with i' e county builii g Insp 'tion COUNTY OF LOS ANGELES BUILDING AND SAFETY
de a?ment j
Dore ?/j�J�f Applicant_. .h FOR APP ANT TO FILL IN CONNECTION DATA
/' �ERTIFt ATE OF FX 1 M N FROM WORD, S' BUILDING `r
� ri c-,:.TION DEPTH
COMPENSATION NSURAN Cr-' - (� ADD
REss F i �! Fy.
(This section need not be completed if the work involved by the `' NL"JHOIE REFERENCE owER
!�1!l OCALITY
permit Is for one hundred dollars (six)or less j TYPE OF CONNECTION
NEAREST +� LENGTH FROM
I certify that in the, performance of the work for which this CROSS ST. ' ['�L:�- Y CURB P L ML TOP L
permit is issued, f shall not employ any person in any manner LEGAL Pc NO
so as to become subject to the Workers'Compensation Lows. DESCRIPTION LOT NO. CO IMP NO JOB NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date_ Apphcont_
NOTICE TO APPLICANT: If, after mak,n this Certificate Of ASSESSOR AFFIDAVIT WP,iVER EASEMENT RECORD WSTR NO DATE
g MAP BOOK PAGE PAH(;EL
Exemptor), you should become subject to the WorkersNO OF SLOGS,
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
PERMIT NO
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter OWNER tfj
9 (commencing with Section 7000) of Division 3 of the Bus,- AIL ADDRESS P � CHARGES
ness and Professions Code, and rO
license is in full force and p/ 7�
effect, CITY TEL NO. G CNNECT OM CHARGE FEE
License Number, E Lit. Class 4 y7 REIMBURS=.nAENT FEE
CONTRACTOR �✓ +<,I �� �` CI$TRKT NO GROUP MAP PROCESSED 8Y
Controctor' - QG Date
ADDRII
ESS YJ�Z.,e'� BK PG l
I am exempt under Sec. . of if,e;.A. Cu. >i � o p
arY !� ti. ,y TEL. vg 't_. G Grp yf -f- CL
0
Plumbing Code and or Sec. of the STATE uc FINAL U
LICENSE No DATE VALIDATION z
B. 13 P. Code for the following reason NO. DEttRIPTION OF WORK FEE �A
HOUSE SEWER CONNECTING TO FINAk
Gate— PUBL C SEWER B,
SEPTIC TANK SEEPAGE PIT OR ! - UJI
Signature C _ �`• -� PITS AND OR DRAINFtELD
HOUSE SE WER CONNECTING TO — Z
WNER- ECLARATION PRIVATE DISPOSAL SYSTEM
I hereby affirm th t I am exemp from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.5; Buisness and Pro- WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT DRA,NFI'EfD - -
fesSions Code):. ExTN CESSPOOL DRYWELL..MANHOLE
w
1, as owner at the property, or my employees with wages as
ALTER REPAIR OR ABANDON HOUSE ]
SEWER OR DISPOSAL SYSTEM -
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code).
1, as owner of the property, am exclusively contracting with ? m M
licensed contractors to construct the project (Section 7044, OWNER'S Permit $ -f-
Business and Professions Code;. AUTHORIZATION TOTAL FEE T 3-,f5-
CONSTRUCTION
`jCONSTRUCTION LENDING AGENCY I HAVE AT THI$ DATE A cc NTRACT w TH THE HERE N NAMED CONiRA:TOR TO
hereby affirm that there i5 o ::onsfrUcfioR lending agency CONNE.:I THE ABOVE D,SCR,BED EXISTING D.NE:iJNG TC,THE PUBI C..SEWER
for the performance of the work for which this permit is
issued (Sec 3097, Civ C.', SIGNED THIS DAY OF 19�
i,WNER OR
Lender's Name_--"-- OWNERS AGENT
Lender's Address----------
1 certify that I have read this application and state that the
above information is correct, 1 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-me is ed p gperty far nspect n put ores.
R°--�. . mature Of Per e D e — SEE REVERSE FOR EXPLANATORY LANGUAGE