Loading...
HomeMy Public PortalAbout5323 WELLAND AVE_Sewer__ 6 WORKERS' COMPENSATION DECLARATION .r hereby C affirm that I have a certificate of consent to reit 20-0051 DPW 6189 Fr insure, ar a certificate of Workers'Compensation Insurance, or 76A6420 a cert"i, , copy therr?of (Sec 3800. Lob APPLICATION FOR PERMIT Policy,No -.Company`_i _ (?Cer d� 4 � eby furnished. SEWER - SEWAGE DISPOSAL (� Certified copy is filed wi�tounty buildington COUNTY OF LOS ANGELES BUILDING AND SAFETY dep'a'rtment. Date C Applicant_.- r ,st1 t k� ; ( FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUDING COMPENSATION INSURANCE ADDRESS AnpN DEPT" (This section need not be completed if the work involved by the - (77` LUPPER OWER REFERENCE permit Is for one hundred donors ($100)or less.) LocALITY NEARESTti TYPE O£CONNECTION LENGTH FROM certify that in rhe performance of the work for:which this CROSS ST CURB P L ML TOP L permit is issued, I shall not employ any person In any manner ECAL. PC NO so as to become subject to the Workers'Compensation LowsDESCRIPTION LOT NO. CO IMP NO !OB NO Date _Applicant BLOCK TRACT TRUNK PERMT NO ROAD PERMIT NO NOTICE TO APPLICANT If, after making this Certificate of MAPASSBOOR AF£IDAVIr WAIVER EASEMENT RECORD IrSTR NO DAre - g MAP ROOK PAGE PAF+C Ea. Exemption, you should become subject to the Workers' No.OF BLDCS. Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF _ revoked. BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER �e ."Z y e-7 9 (commencing with Section 7000) of Division 3 of the Bus,- MAIL - ADDRESS ^ T'2x;••+ HARGES ness and Professions Code, and myr license is in full force and effect CITY VIA TEL NO Itf 7 �ONNECTION CHARGE FEE License Number 41V, V 76' LIC.Class �� ' / /y +j $ COJTRACTOR REIMBURSEMENT FEE Contractor Z� Z- e&`94 Date /� DISTRICT NO GROUP MAP- PRO,tSSED BY .. ADDRESS � BK PG q I am exempt under Sec. of the L.A.Co. r � ) '1 F atv / 3 TEL_NO. � ���'i�'�" v�' t!"� , 0 Plumbing Code and;of Sec. of the STATE uC. FINAL OU UCENSE NO cL.Ass Z-. DATE �f 7 vp� VA IDAf'10N B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE G!�" L Q HOUSE SEWER CONNECTING TO FINAL Date PUB.•C SEWER - :V. BY (� SEPTIC TANK SEEPAGE PIT OR LU Signature PTS AND .2R DRAINFla E D U)FOUSE SEWER CONNt- NG TC' OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM PooZ I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OP ' Law for the following reason (Secton 7031.5, Buisness acid Pro WORK TO HOUSE SEWER fessions Code) OVFRFLOW SEEPAGE PIT DRAINFIELD EX1N CFSSPOOI. DRYWEI.L.MANHOLE I, as owner of the property,or my employees with wages as ALTER REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM their sole compensolion, will do the work and the structure — Is not intended or offered for scale (Section 7044. Business and Professions Code'I. ❑ I, as owner of the property,am exclusively contracting with OWNERS Permit $ !.. licensed`contractors to construct the project (Section 7044, Business and Professions Code). AUTHORIZATION I TOTAL FEE t� CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT w TH THF HEREIN NAME NTRACTOR To ► I hereby affirm that there is a construction lending agency C©NNEc' THE ABOVF DESCRIBED EXISTING D WELLIN-TO THE PL,&L SEWER for the performance of the work for which this permit Is issued (Sec. 3097, Civ. C.1. SIGNED THIS�fCl DAY OF 19 e,.2 _ OWNER OR Lender's Name_ OW NE R;i AGEN - Lender's Address ADDRESS I certify that I have read this opphcation and state that the above information is correct. I agree to comply with all County ordinances and State laws regu ting Plumbing and Sewers, and hereby authorize represer tives of this County to enter upopi-"rht- bove-mentioned p petty for inspection spectin purposes Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE