HomeMy Public PortalAbout5853 SULTANA AVE_Sewer__ �Wd)RKI�RS'COMPENSATION DECLARATION
vhereby ObObcm that I hove a certificate of consent to self jl
`nsu?e, ora certificate of Workers'Compensation Insurance, or 76A642D U
a certified copy thereof (Sec. 3800, Lob C. rL 506 REV 1 APPLICATION FOR PERMIT
Policy No. Company
El Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
J 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 -_----
COMPENSATION INSURANCE ,-z STATION DEPTH
ADDRESS ~r '
(This section need not be completed if the work involved by the —,
he 's MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY LOWER
I certify that In the performance of the work for which this CROSSSST. TYPE OF CONNECTION LENGTH FROM
Y. CURB P1. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. y� ,� P.C.NO.
� p OWNER ,+'°+°;. '" CO.IMP.NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS ? `
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL,NO. AFFIDAVIT WAIVER EASEMENT RECORD.INSTQ NO. DATE
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF PERMIT NO
LOT
SIZE OF LOT NOW ON LOT (i
I hereby affirm that I am licensed under provisions of Chapter USE of
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS _ CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOd CONNECTION CHARGE FEE
.._-.
License Number Lic.Class ADDRESS `i REIMBURSEMENT FEE
Contractor Date DISTRICT NO. GROUP MAP PROCESSED BY
CITY '.,,/':� TEL.NO, s- _ O
- BK PG V
❑ i am exempt under Sec. of the L.A.Co. LICENSE NO �` CLAS$
U
NO DESCRIPTION OF WORK FEE O
Plumbing Code and/or Sec. of the FINAL F„
-HOUSE SEWER CONNECTING TO DATE VALIDATI N
PUBLIC SEWER _ V
B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR , LU
PITS AND/CR DRAINFIELD FINAL / N
Date HOUSE SEWER CONNECTING TO BY r Z
PRIVATE DISPOSAL SYSTEM
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
Low for the following reason (Secton 7031.55, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code):
SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as ,
their sole compensation, will do the work and the structure z
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit _�$ s 0 s 1
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
r
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO G. 1,50
0
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER,
CONSTRUCTION LENDING AGENCY • o 2- 1,E�C s
SIGNED THIS—DAY hereby affirm that there is a construction lending agency SAY OF 19 ►
for the performance of the work for which this permit is OWNER OR 9,0r ""8 q
4 5
Issued (Sec. 3097, Civ. C.). OWNERS AGENT
ADDRESS
Lender's Name
Lender's Address
I certify that I hove read this application and state that the
above information is correct. I agree to comply with ail County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
uporrt-*6_6 ove-mentioned property for inspection purposes.
Signature of Pqyrmittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE