HomeMy Public PortalAbout6167 SULTANA AVE_Sewer__ -WORY'P-RS'COMPENSATION DECLARATION
I hereby,,'affirm that I huve a certificate of consent to self
Insure, or a certificate of Workers'Compensation Insurqnce, or 76A642D i 7`
a gertified oapy thereof (Sec. 3800 Gab C.) C:F 80B(REV.B/81) APPLICATION FOR PERMIT
Policy No...,! i'.i'i Company 'L t_ <'i.%
❑ Certified copy is hereby furnished.. SEWER - SEWAGE DISPOSAL
:'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 J STATION DEPTH
COMPENSATION INSURANCE ADDRESS_ '
(This section need not be completed if the work involved b the UPPER
Y MANHOLE REFERENCE
permit is for one hundred dollars ($100)or less.) LOCALITY LOWER
NEAREST - TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L.TOP.L.
permit is issued, I shall not employ any person in any manner P.C.NO.
so as to become subject to the Workers'Compensation Laws. OWNER co.IMP.No. JOB No
MAIL
Date Applicant ADDRTRUNK PERMIT NO. ROAD PERMIT NO.
r _ .--- — .-------_.._--
FIDAVIT W
NOTICE TO APPLICANTS If, after making this Certificate of cert TEL NO. AVER EASEMENT RECORD.INSTR.NO. DATE
AF
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HW'Y-OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT _ — PERMIT NO
OACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS
SIZE OF LO 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 , , > CONNECTION CHARGE.FEE
,. � ,.� CONTRACTOR _ - -� �-
License Number-�'. 4.i" '� Lic.Class J ' "
CL
ADDRESSi`? - REIMBURSEMENT FEE 0
Contractorr %'C —Date 1 y DISTRICT NO. GROUP MAP CSCE ED BY
CITY TEL.NO. -� -
+ STATE u LIC. � BK PG Z
EJI am exempt under Sec. of the L.A.Co. LICENSE No CLASS AJ- - -<_
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL 4?
HOUSE SEWER CONNECTING TODATE L� ' VALIDATION w
B. & P. Code for the following reason Pusuc SEWER
SEPTIC TANK,SEEPAGE PIT OR Z
PRS AND/OR GRAINFIELD FINAL AC
Date HOUSE SEWER CONNECTING TO BY IJJ
PRIVATE DISPOSAL SYSTEM
Signature. CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK i0 HOUSE SEWER
OVERFLOW SEEPAGE PIT,DR.AINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN_CESSPOOL,DRYWELL,MANHOLE V
Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ 1,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 Permit $ j Lj
and Professions Code). OWNER'S
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE i "� t0 1. 1 A
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, �.} W • 1 !_
CONSTRUCTION LENDING AGENCY f#
_
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19 f � - 21, 50
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT , X
ADDRESS
- I,
Lender's Name
Lender's Address
I certify that 1 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.
-Xz
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE