HomeMy Public PortalAbout6227 SULTANA AVE_Sewer__ • WORKERS'COMPENSATION DECLARATION
'! here'by,pff,icm'that l' have a certificate of consent to self
imure,`or a certificate of W r ers'Compensation Insurance, or 76A642D
a certifiedr., p OO, �a , soa(REV., 31 APPLICATION FOR PERMIT
Polk No � m n � ��'° ->«
y p y SEWER - SEWAGE DISPOSAL
ertified copy is hereby furnished.
❑ Certified copy is filed wicou �Idinginspec�:h theCOUNTY OF LOS ANGELES BUILDING AND SAFETY
department.Q
Date r� '�C .Applicant FOR APPLICANT TO FILL IN CONNECTION DATA J
CERTIFICATE OF EXEMPTION FROM WORKERS' BULDIN
�1(�i STATION r � DEPTH I
COMPENSATION INSURANCE II
(This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE !� m�^� L"}� UPPER
permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this NEAREST Y. TYPE OF CON N LENGTH FROM
CROSS ST. CURB
PL M.L.TO P.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 �'') TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS J
tw - � l"* AFFIDAVfT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY tEL.No.
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
'" NO.OF LCITS -1y,_ PERMIT NO.
LICENSED CONTRACTORS DECLARATION size of LOT ,- J� Now ON LOT�C"Cz-
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 CONNECTION CHARGE FEE
License Number -Lic.Class ADDRESS I REIMBURSEMENT FEE }
COnt(OCtaf Date f f DISTRICT NO. GROUP MAP PROCESS BY a•
CITY (,,..yl' O. e. 11 BK PG V
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO CLLASs �✓t ,r
NO. DESCRIPTION OF WORK FEE O
Plumbing Code and/or Sec. of the FINAL
HOUSE SEWER CONNECTING TO - 4 DATE VALIDATION V
B. & P. Code for the following reason PUBLIC SEWER �✓ LU
SEPTIC TANK,SEEPAGE PIT OR FINA d•
PITS AND/OR DRAINFIELD in
Date HOUSE SEWER CONNECTING TO B 4 Z
PRIVATE DISPOSAL SYSTEM _
Signature CONNECT ADDITIONAL BLDG.OR 0
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ' L� , 4 �\
OVERFLOW SEEPAGE PIT,DRAINFIELD 1
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE #kt 1
Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE tt • • • • 1
fessions Code): SEWER OR DISPOSAL SYSTEM -
❑ f, as owner of the property,or my employees with wages as
1 • � v050
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business 5 • • • 6 0 5 0
and Professions Code). OWNERS Permit $
XI,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE J, 0 t 1, 04-85
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
ADDRESS
Lender's Name
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 nd State laws r gulating Plumbing and Sewers,
and here Authorize repr. entatives of this County to enter
upon the ave-mention property for inspect; n purposes.
Mtittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE