HomeMy Public PortalAbout5953 SULTANA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
nsur,, or a certificate of Workers'Compensation Insurance, or '6A642D
a certified c py thereof (Sec. 3800, Lob C.) CE 808(REV.8;81) APPLICATION FOR PERMIT
Policy No. Company "�1—,,, 4 f!1`vf d Pis
E] Certified copy is hereby furnished. I SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection 63 COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. 11 1
Date" Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ADDRESS � STATION DEPTH
(This section need not be completed if the work involved by the Q- e MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY 6c_. `� LOWER
I certifythat in the performance of the work for which thiS NEAREST TYPE OF CONNECTION LENGTH FROM
P CROSS ST. V LAef Y. CURB P,L, M.L.TO P.L.
permii is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. owNER Al CO.IMP.NO. JOB NO.
t�
MAIL
Date Applicant ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO i 8
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
44
NOTICE TO APPLICANT: If, after making this Certificate of CITY r TEL.No
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. 'M HWY_OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT ,1STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION ,.+ NOW NO. ON LOT OF BLDGs. PERMIT NO.
I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT t..'USE of - s" T{•r
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. CONTRAQR CONNECTION CHARGE FEE
License Number Lic.Class AD ESS REIMBURSEMENT FEE
Contractor DateDISTRICT NO. GROUP MAP PROCESSED BY
Tv , T >7vo.
am exempt under eca of the L.A.Co. s LEN UC. _ 3 B 2
Eli dSec. L SE NO. CL
S C- . .]
Plumbing Code and/or Sec. of the DESCRIP. O r OFORK I FEE FINAL VALIDATION
HOUSE sEWEk ON { GTO DATE
B. & P. Code for the following reason UBLIC SEWS K,SEEPAGE PIT OR
PITS ' R DRAINFIELD FINAL
Date HOUSE SEWS NECTING TO BY _
PRIVATE DISPOSAL SYSTEM
-
Signature CONNECT ADDITIONAL BLD . ,
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 (Seeton 7031.5, Buisness 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
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S I Permit $ C>
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION 1 TOTAL FEE ( S G
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
Lender's Name ADDRESS
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 authorize representatives of this County to enter `rf
upon the above-mentioned property for inspection purposes.
Sign to f er f Pt e a e� SEE REVERSE FOR EXPLANATORY LANGUAGE
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