HomeMy Public PortalAbout5955 SULTANA 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 c pyy thereof(Sec. 3800, Lab C.) _ CE 808(REV.8/81) APPLICATION FOR PERMIT
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Policy No. -F —Companys f- 1:, ' (I�s
Certified copy is hereby furnished, SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection 'G'
COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
C
Date.. q-� Applicant - FOR APPLICANT TO FILL IN ;EE
ONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WOR ER ' BUILDING SDEPTH
COMPENSATION INSURANCE ADDRESS /
(This section need not be completed if the work involved by the CCAiIT `� REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) OWER
NEAREST PE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS sT CURB P.L. M.L.TO P.L
permit is issued, I shall not employ any person in any manner ii
so os to become subject to the Workers Compensation Laws. P.C.NO. 0
OWNER CO. JOB tJO.
MAIL
�.
Date Applicant
ADDRESS „ TMIT NO, ROAD PERMIT NO.NOTICE TO APPLICANT: If, after making this Certificate of LEL NO. IT WAIVER EASEMENT RECOR NO DATE
Exemption, you should become subject to the Workers'Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. ST.WIDENINGcomply with such provisions or this permit shall be deemedrevoked. BLOCK TRACT SROACHMENTLICENSED CONTRACTORS DECLARATION r 40OF BLDGS. P
SIZE 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 Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR VDATE
CHARGE FEE
License Number Lit.Class ADDRESS ` NT FEE
Contractor Date i . GROUP MAP PRO SSED BY
CITY TEL.NO, - /�-
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO LIC
CLASS (�, 8PNO. D CRI N F W R FEEPlumbing Code and/or Sec. ofthe HOU R CONNECTIN O `r _ VALIDATION
B. & P. Code for the following reason Pu6uC sew ,' ;,SEPTIC TANK,SEEPAGDRAIN RPITS AND%OR DRAINfIELCDat@ HOUSE SEWER CONNECTING TO _ ,j° *-. •,,,^,
PRIVATE DISPOSAL SYSTEM. ae—
Signature �" CONNECT ADDITIONAL BLDG.OR
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE f
Low for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL.SYSTEM
1
❑ I,as owner of the property,or my employees with wages as \V!
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit $ s s
L! I, as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE _ C%
licensed contractors t0 COnS1rUCt the project (Section 7044, I 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—
far the performance of the 'work for which this permit is OWNER OR
issued (Sec. 3097, Civ. Cr). OWNERS AGENT—^ ADDRESS 1
Lender's Name
Lender's Address
Icertify 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, °
~ C
nd hereby authorize representatives of this County to enter
pon the above-mentioned property for inspection purposes. W U�
Signature adT'erm tt Date SEE REVERSE FOR EXPLANATORY LANGUAGE