HomeMy Public PortalAbout6240 SULTANA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
20-0051 DPW 6189
! hereby affirm that I have a certificate of consent to self
insure„ or a certificate of Workers' Compensation 76A642o
sation Insurance, or.
a certified copy thereof (Sec 3800, Lab C , APPLICATION FOR PERMIT
Policy No.__ -__Company
❑ 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 / 2 /.� � �- ry ST,T DN DEPTH
4 14—
COMPENSATION INSURANCE ADDRESS (®
(This section need not be completed if the work involved by the r MANHOLE REFER€r:CE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY �� f OWER
TYPE OF CONNECTON
certifythat in She performance Of the Work for whiff this NEAREST __`` LENGTH FROM
pe CRC_;`.;ST- fit! V Y CURB PL M; TOPIL
permit is issued, I shall not employ any person in any manner LEGAL P: NO
so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO. Z-,m Z CO :MR NO JOB NO
�---� BLOCK TRACT O TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant Z---2 J
NOTICE TO APPLICANT: If, after making this Certificate of ASSESSOR 2 AFFIDAVIT WAIVER EASEMENT RECORD wsrR NO DATE
g MAP BOOK J J � PAGE PARCFI.
Exemption, you should become subject to the Workers' �r NOof 5LDGS
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT Q ! 4-S NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
4
LICENSED CONTRACTORS DECLARATION 0 '« �� ,�
I hereby affirm that I am licensed under provisions of Chapter OWNER �J � PERMIT NO
'
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL �/ ^ t �� ( V'i /,�
CHARGES
Hess and Professions Code, and mJ license is in full farce and ADDRESS b--�,
effect. CITY J/��s.-• ,,.JQ TEL NO. CONNECTION CHARGE FEE
License Number Lis.Class cONTRACMOEt RE°MBLASEMENT FEE
Contractor Date /"�f �7 DISTRICT NO GROUP MAP PROCESSED BY
ADDHE::S L>7 �^-(4I/ �t.� �?/�I/ - .� BK PG . ,r
❑ I am exempt under Sec —of the L A. Co. / /� r `J Y
CITY �. TEL.NO.Zt�G ^� /t'7 L rU:t -../q +,..� /J 4�T � 4�'�' �• +�^1 n.
Plumbing Code and/or Sec. of the STATE Lin FINAL �f ✓
LOENSF NO. CLASS DATE yl, f ./ VALIDATION Z
B. & P Code for the following reason NO. DESCRIPTION OF WORK FEE 0
HOOSE SEWER CONNECTING TC FINAL
Date PUBLIC SEWER B'v (�
SEPTIC rANx SEEPAGE PIT GR W0.Signature PTS AND OR DRAiNFI LD - 0.
OWNER-BUILDER DECLARATION I-TOUSEPRIVATE
SEWER COL SYS INC rO , Z
PRIvATE U�POSAL SYSTEM
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSESEWER
fessions Code): CVERFlO:y SEEPAGE PIT. DRAINFIEtD
EXTN CESSPOOL DRYWEIL.MANHOLE
❑ I, as owner of the praperty, or my employees with wages as Ai TER RE°A'ISPOSAL SYSTEM R OR ABANDON HOUSE
SEWER OR D
their sole compensation, will do the work and the structure
is not Intended or offered for sale (_Section 7044, Business
and Professions Cade).
L-_J I, as owner of the property, am exclusively contracting with Permit $
licensed contractors to construct the project (Section 7044, OWNER'S
Business and Professions Code). AUTHORIZATION TOTAL FEE +' b
CONSTRUCTION LENDING AGENCY I HAVE AT THIS ,ATE A CONTRACT r H THE. HERE!N NAMED CONTRACTOR
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTIN„L.yELUNG_TO THE PUBIC SEWER
for the performance of the work for which this permit is
issued (Sec- 3097, Civ. C ) SIGNED THIS DAY OF Iv
OWNER OR
Lender's Name---__—_-- ---_--^ OWNERS AGENT - .. .
Lender's Address___..,____. 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
upon the above-mentioned property for inspection purposes.
a-- _ __=_fir-r-4-5--71y
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE