HomeMy Public PortalAbout5401 WELLAND AVE_Sewer__ `WORKERS'COMPENSATION DECLARATION
92-0002 DPW 3/$7
l• hereby'alfirm that I have a certificate of consent to self �
„Poluce,•^rd certificate of Warakers'Compenationsurance, or 5 CCE is DBD APPLICATION FOR PERMIT
a eertwify�d a d eE €' ec- 3800, Lab
Y p Y
AJ_41❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
ertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
d rtment.
Date Applicant ' —* F R APPLICANT;TO:.f I IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING ^ ` STATION V�y DEPTH
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by theUPPE
LOCALITY MANHOLE REFERENCE ! ER
permit is for one hundred dollars ($100)or less.) LENGTH FROM
NEAREST TYPE OF CONNECTION _
I certify that in the performance of the work for which this CROSS ST. Y CURB P,L. M.L TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. P.B NO.
I p OWNER L. CO IMP.NO. JOB NO,
Date Applicant
ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after making CITYJJA_ TEL.NOthis Certificate of �r AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO. DATE
.
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 f
revoked. BLOCK TRACT j D STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. Wi 'LL w
SIZE OF LOT 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 Co e, and, y license is in full force and
effect. CONTRACTOR CONNECTION CHARGE FEE
License Numbe, C.Class + ADDRESS REIMBURSEMENT FEE
Contractor �" Date 's Lr3 DISTRICT NO. GROUP MAP PROCESSED BY (}
CITY _ L.NO. BK PG. `� _ Z
STATE � LIC. �' ✓" 2
❑ 1 am exempt under Sec. of the L.A.Co. ucENse No CLASS <� "?� )*
i—
NO. E5 IPTIONOF - ORK EEE
Plumbing Code and/or Sec. of the FINAL
HOUSE SEWER CONNECTING TO '`; '`" DATE "!'1VALIDA40' N W
PUBLIC SEWER
B. & P. Code for the following reason i N
PITSPITS TANK,SEEPAGE PIT OR FINAL Z
AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ►
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License I EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE C 0 7. r A.
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as 1 'C€
their sole compensation, will do the work and the structure �,7 I
is not intended or offered for sale (Section 7044, Business t t u
and Professions Code). OWNERS Permit $
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION r TOTAL FEE 1 _ 7''5 0
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ^� ar .
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER �I �� �,J 6
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
L 'nder's Address
I c' rtify 1 I have read this application and state that the
ve inf r anon is correct. I agree to comply with all County
o d none sIn d State laws regulating Plumbing and Sewers
her s uthorize representatives of this County to enter
u n the ab ve-mentioned property for Inspection purpose Ni (Jwb
fy
gnature Permittee Dat SEE REVERSE FOR EXPLANATORY LANGUAGE