HomeMy Public PortalAbout6019 SULTANA AVE_Sewer__ WOUKERS'COMPENSATION DECLARATION CE 8508° Saf A P P L I CATION FOR PERMIT
I hereby affirm that I have a certificate of consent to Self SEWER—SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES ✓' BUILDING AND SAFETY
a certified copy'thereof(Sec. 3800.Lab. C.)
Policy No. Company CONNECTION DATA
FOR APPLICANT TO FILL IN
Certified copy is hereby furnished. STATION DEPTH
BUILDING I 3 y^
❑ ADDRESS +� �} UPPER
Certified copy IS flied with the COL]ntV"building inspection MANHOLE REFERENCE
department. LOCALITY ,.'�,ry' A LOWER
L)aYe Applicant NEAREST TYPE OF CONNECriON LENGTH FROM
CROSS ST. Y. -.. CURB P.L. M.L. TO P-L.
CERTIFICATE OF EXEMPTION FROM WORKERS' _ P.C. NO.
COMPENSATION INSURANCE OWNER a �. J: CO. IMP. NO. JOB NO.
CIL
MAIL ,�f C'g
(This Section need not be completed if the QQ�work involved ADDRESS 9 JJ// TRUNK PERMIT NO. ROAD PERMIT NO. L)by the permit is for one hundred dollars ($100) or less.) / AFP IDAVIT WAIV EH EASEMENT RECORD. INSTR. NO. DATE
CITY ,.. TEL. NO. .' C cc
I certify that in the performance of the work for which this LEGAL
permit is Issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING
SU as to become subject to the workers' Compensation Laws, STATE ENCROACHMENT LU
BLOCK TRACT PERMIT NO.
Applicant NO. of BLDGS, to
Date
SIZE OF LOT NOW ON LOT z
NOTICE TO APPLICANT: If, after making this Certificate of USE of
Exemption, you should become subject to the Workers' �y CHARGES
BUILDINGS
Compensation provisions of the Labor Code, you must forth- CONNECTION CHARGE FEE
with comply with such provisions or this permit shall be CONTRACTOR
deemed revoked. REIMBURSEMENT Fee
LICENSED CONTRACTORS DECLARATION ADDRESSDISTRICPr+OCEssED BV
9"NCD, GROUP MRP
PG
CITY I hereby affirm that I am licensed under provisions of Chapter TEL. NO. BK
-
9 (commencing with Section 7000) of Division 3 of the Busi- STATE LIC.
ness and Professions Code, and my license is in full force and LICENSE NO. CLASS
effect. NO. DESCRIPTION OF WORK FEE FINAL V LIDATIO.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER DATE
License Number Lie.Class —__
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR ORAINFIELD FINAL _
Contractor Date HOUSE SEWER CONNECTING TO BY
PRIVATE- DISPOSAL S�STEM
F1I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER R -
OVERP-LOW SEEPAGE PIT,OR AINFIE LD
acting in my professional capacity (Section 7051, BUS- EXTN.,CESSPOOL,DRYWFLL,MANHOLE
mess and Professions Code). ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lie,or Reg.No. Date
HOME OWNER,BUILDER.DECLARATION --
hereby affirm that I am exempt from the Contractor's
OWNER'S Permit =
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE -
ness and Professions Code): 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
Y
RACTOR O CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
T
I, as owner of the property, will do ttie work and the TO THE PUBLIC SEWER.
structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19-
7044,Business and Professions Code). OWNER OR
OWNERS AGENT ---
CONSTRUCIION LENDING AGENCY ADDRESS
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
Lender's Address
1 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
upon the.above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date