HomeMy Public PortalAbout6335 SULTANA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure,%r a certificate of Workers'Compensation Insurance, or 7ene42D
a certified copy thereof (Sec. 3800, Lab C.) cE808(REV,1/83) 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 APPLICA TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGrJ
COMPENSATION INSURANCE ADDRESS '�""` '�', '"
,P 1,' STATION ) DEPTH YG
(This section need not be completed if the work involved by the f�J1+ r� l MANHOLE REFERENC 7 73, i)� 1� PP ER
NEAREST
permit is for one hundred dollars ($100)or less.) LOCALITY
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 PC NO,
so as to become subject to the Workers'Compensation Laws. OWNER ) C CO.IMP.NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Dote Z-- Applicant j.�.,J ADDRESS
NOTICE TO APPLICANT: If, after makin this Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR NO DATE
g CITU 7E1.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 _&,%.: A y
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS -re" ✓ CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTORCONNECTION CHARGE FEE
License Number ;2 D 2 6✓a lit.Class 5 24" ADDRESS .—
�F/, � � s" � � �� /Q�°7�„J REIMBURSEMENT FEE �
Contractor /'/„) ac"L-1'.:�'l Date --'% DISTRICT NO. GROUP MAP PROCESSED BY O
'` CITY ' 1 ', 1114 TEL.NO. �r!'� _6 �_7�� s�-,, /)u P.� BK PG ;t U
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO, 21 0 '� �� UC. �— �7t °� tT �1 ✓ � �t
CLA55C"-- �
Plumbing Code and/or Sec. of the NO DESCRIPTION OF WORK FEE FINAL V
HOUSE SEWER CONNECTINGPUBLIC SEWER TO i I DATE VALIDAT ON LU
B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR r V J N
PITS AND/OR DRAINFIELD FINAjq^ �2 5 a 8 A Z
Date PRIVATE DISPOSAL
HOUSE SEWER ONSYSTEMG 70 BY J + • •
Signature CONNECT ADDITIONAL BLDG OR i L
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER - 27,5>�
I hereby affirm that I am exempt from the Contractor's license OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE • • - 2 /7
,5 03
fessions Code): SEWER OR DISPOSAL SYSTEM _
❑ I,as owner of the property,or my employees with wages as 07,29-85
their sole compensation, will do the work and the structure
is not intended or offered for sole (Section 7044, Business
and Professions Code), OWNERS Permit $
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct 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 _
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENTADDRESS
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 and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-mentioned proper for inspection purposes.
Signature of Permi1ree Date SEE REVERSE FOR EXPLANATORY LANGUAGE