HomeMy Public PortalAbout5637 SANTA ANITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION �j
M2D-cosi DPW sites U
1 hereby affirm that I have a certificate of consent to self 7BA6420
insure, or a certificate of Workers' Compensation Insurance, or
a cereNfied copy thereof (Sec 3800, Lab C , APPLICATION FOR PERMIT
Policy No._------Company._ -----___- - p
❑ Certified copy is hereby furnished, SEWER - SEWAGE DISPOSAL
L] Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Vote _-Applicant.___ FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING r;'
COMPENSATION INSURANCE ADORFss y fL;• ATION l - DEPT"
(This section need not be completed if the work involved by the v ',ANHr�Le REFERENCE V F UPPER
permit is for one. hundred dollars ($100) or less.) LOCALITY zL � f p, , F`i� O R
NEAREST _ TYPE OF CONNECTION LENGTH FROM
I certify that In the performance of the work for which this CROs ST L.,< ..... , 5 CURB P L M L TOPE
permit is issued, I shall not employ any person m any manner LEGAL PC NO
so as to become subject to the Workers�en� Laws. DESCRIPTION LOT NC) D IMP NO )OB NO
BLOCK TRACT "ZUNK PERMIT NO ROAD PERMIT NO
Gate � c APplicar.f-��'k.
NOTICE TO APPLICANT: I{, after makln 1hi5 Certificate Of ASSESSOR P ._� f gr,a„� AFFIDAV',T WAIVER EASEMENT RECORD INSTR NO DATE
g NAP HOOK 1 PAGE�`�d PARCEL�a,.-11
Exemption, you should become subject to the Workers' NO.oP BLDGS
Compensation provisions of the Labor code, you must forthwith gaze OF LOT NOW ON LOT PINY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF _
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION S l y L PFRMIT No
I hereby affirm that I am licensed under provisions of Chapter OWNER Jr E,' J ,fai t
9 (commencing with Section 7000) of Division 3 of the Busl- MAIL _ J_ S #
ness and Professions Code, and rn�'license is in full force and ADORess tfjv CHARGES
1
effect. CITY. 7 TEL NO. CONNECTION CHARGE FEE
License Number 1-OA [Tt Lic. Class `-3 REIMBURSEMENT FEE
�/�J //r) ,�s CONTRACTOR .•r;� �•G.
Contractor`-"'"t:21, CUf F9 Date �J - �U-s F7 _ y{ DISTRICT NO GROUP MAP PRO
r ADDRFSS i• :.�-'F 1 � e,'1i J- BK. PG
] I am exempt under Sec. of the L.A.Co. i 7 rot.C'
oe
CITY [ Ge�/c�tJY TEL NO
Plumbing Code and,or Sec, of the STATE LIC NAL 0
LICENSE NO. ,71—ear;� CLASs ;ZT€ � de's VALIDATION z
B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE C)
HOUSE SEWER CONNECTING TO "j F'.NAi
Date (
PUB,C SEINER 7� B, �✓�f �j
SEPTIC TANK SEEPAGE PIT OR
Signature P S AND OR DRAINFIEtD CL
HOUSE J
OWNER-BUILDER DECLARATION PR NATSEWER COrd NECTIrG TO 0)
E DISPOSAL SYSTEM ® ?
ereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
!.o.v for the following reason (Sedan 7031 5, Buisness and Pro- WORK TO HOUSE SEWER
`e'sio-ls Code): O ERI ;IN SEEPAGE PIT DRAINFIELD - u,
Er TN CESSPOOL DRYWELL MANHOLE
-
CIS owner of the property, Or my employees With wages ALTER REPAIR OR ABANDON HOUSE
aS SEWER OR D'sPOSAL SYSTEM
"-ev sole COmpe.nsation, will do the work and the structure
s not intended or offered for sale (Section 7044, Business .''.
ind Professions Code).
as owner of the property, am-exclusively contracting with OWNER'S Permit $ (��
-rinsed contractors to construct the project (Section 7044,
,mess and Professions Code). AUTHORIZATION FTOTAL FEE
CONSTRUCTION LENDING AGENCY HAVE AT iH!S ATE A Ct NiRAC-7WJ1. THE NfRiW 'dAME� CO TRACTfJR TO
r affirm that them Is a construction lending{tg
1 , agency CONNECT SHE ABOVE DEScCRIB'ED cxtcTtNC DNEU
LNG TD'HE PU5i�iC SEWER
,
for ;erformonce of the work for which this permit is
SSUC„ I'iec. 3097, cvv C ) SIGNED THIS DAY OF
OWNER OR j�
a Lend( s t -'
.,•� Nar'ne U _ OWNERS AGENT
Lender's Address ADORES'
I certify Y "hat I have read this application and state that the
above inrnrmation: is correct, I agree to comply with all County
,• ordinance,, and State laws regulating Plumbing and Sewers,
and here;;.; authorize representatives of this County to enter
upon the;.,ovS�z • Toned property for Inspection purposes.
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Signature -,f Permitteepale SEE REVERSE FOR EXPLANATORY LANGUAGE