HomeMy Public PortalAbout5403 WELLAND AVE_Sewer__ 'JNORKERS' COMPENSATION DECLARATION
'Ns,I herefryf'affirm'that I hav&- a certificate of consent to self 92-0002 DPW 3/87
insure, or 6 certificate of Workers'Compensation Insurance, or 76A642D
a certified c5. there. (Sec. 3800, b CE 808 APPLICATION FOR PERMIT
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Policy No.jj;Er�ompany ts
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deparlmentt
Date?—(^_- tl_Applican FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING ) / STATION DEPTH ¢
COMPENSATION INSURANCE ADDRESS x G�
(This section need not be completed if the work involved by the LOCALITY - MANHOLE EFERENCE UPPER
-
permit is for one hundred dollars ($100)or less.) NEAREST ^ TYPE OF CONNECTION LENGTH FROM ,
I certify that in the performance of the work for which this CROSS ST. CURB PA 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. owNER '—r 9 CO.IMP.NO. JOB NO.
MAIL .! ) "�„„` ,y TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of CITY '✓� Z. / AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO. DATE
TEL.NO.
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Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. C HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT ~ i L- .(. a STATE ENCROACHMENT , •t
LICENSED CONTRACTORS DECLARATIONNO.OF BLDGS. PERMIT NO
SIZE OF LOT7Z_. �.- 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 / L CHARGES
ness and Professions Code, anV y license is in full force and ✓
effect. - �i- CONTRACTOR, -^,GiL. L�„ ,�,'ti CONNECTION CHARGE FEE
License Number c.Class J ADDRESS REIMBURSEMENT FEE
Contract r 1 y Date T c,pJ )x TEL,NO. DISTRICT NO. GROUP MAP PROCESSED BY
CITY
BK PG
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO, CLASS O t�1
Plumbing Code and/or Sec, of the NO/I 6ESCIRIPT'ION OF WORK FEE FINAL OJL
HOUSE SEWER CONNECTING TO -' DATE ..� ...� VALIDA, bN
B. 8 P. Code for the following reason PUBLIC SEWER � u
SEPTIC TANK,SEEPAGE PIT OR LINPITS AND,OR DRAINFIELD
Date--- HOUSE SEWER CONNECTING TO CP
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG,OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER , h + + + • 1 U
I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE r7
Law for the following reason (Becton 7031.5, Buisness and Pro- ALTERv 0,REPAIR OR ABANDON HOUSE e 7'
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as _
their sole compensation, will do the work and the structure + ® • I
is not intended or offered for sale (Section 7044, Business 7,5 0
and Professions Code). OWNERS Permit $ ,} 0706-88
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE
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 poll hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19
e _
for the performance of the work for which this permit is OWNER OR
slued (Sec. 3097, Civ. C.). OWNERS AGENTADDRESS
Lender's Name
Lender's Address
I certifgr that I have read this application and state that the
abovinformation is correct. I agree to comply with all County
ordin Ices and S laws regulating Plumbing and Sewers,
and ereby aut ori' representatives of this County to enter
upon he;abov -me tioned property for inspection purposes'.lj
Sigrioture of Per1ttee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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