HomeMy Public PortalAbout5543 1/2 SANTA ANITA AVE_Sewer__ • -WORKERS' COMPENSATION DECLARATION
I 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.) CE808(REV.881)
Policy No. Company ®a APPLICATION FOR PERMIT
❑ 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 CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING P "o : - STATION DEPTH
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by theLOCALITY � �} a-�"�- •p' 1 LL�\,JER MANHOLE REFERENCE
permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for Which this CROSS NEARESST, TYPE OF CONNECTION M.L LENGTH
Y. CURB P.L. M.L.TOP.
permit is issued, I shall not employ any rson in any nne.
so as to be me subject to the Workers' m ensatio ws. t • P.C.NO.
p OWNER -, �tr h." ,� ✓ CO.IMP.NO. !08 NO.
f +, MAIL ` TRUNK PERMIT NO. ROAD PERMIT NO.
Date �Ipplicont '`'�-''� �' ADDRESS
NOTICE TO A LICANT: If, of}Er makin this P.rtifi to of �.. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR NO. DATE
g CITY ,� m,. L.NO. � v'7�;• 1
Exemption, you should become subject to the orkers' LEGAL 1J
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 PERMIT No.
LOT
slzE 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 BUST- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR / CONNECTION CHARGE FEE
License Number Lic,Class ADDRESS REIMBURSEMENT FEE M_
Contractor Date DISTRICT NO. UP MAP PROCESSED BY U
CITY TEL.NO. fr //i(/���`` hy^ PG 1)CE)
z
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS _::I,. W '
DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. -of the NO. FINAL U
HOUSE SEWER CONNECTING TO ,r DATE �� VALIDATI CL
PUBLIC SEWER
B. & P. Code for the following reasonG
SEP TANK,SEEPAGE FIT OR FINA A
PITS A AND/OR DRAINPoELD ,, ,
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM 1 !r
Signature CONNECT ADDITIONAL BLDG OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License 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
❑ 1,as owner of the property,or my employees with wages as <� �1 `33 Atheir sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, BusinessW
and Professions Code). OWNER'S Permit $ rr • " • i
❑ 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 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 OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT
ADDRESS
Lender's Name a
1'
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 Iuthorize reprA ntatives.pf this County to enter
upon thee-mention p openr inspection urpose�:
eAL �_ :� �.
Signature of Permittee Date € r �
SEE REVERSE FOR EXPLANATORY LANGUAGE