HomeMy Public PortalAbout5405 WELLAND AVE_Sewer__ '?NORKERS' COMPENSATION DECLARATION
,c � 76A642 DPW 3/87
I'here6j affirm that I have a certificate of consent to self
20
%i ,;re, or'a certificate of Workers'Compensation Insurance, or 76A68
a certifi4d cSpy , erea(Sec. 3800 ,b c )) CE B�B APPLICATION FOR PERMIT
Policy N`c1� 3ompany _ 'As
❑ 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 �w'�/ "' FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGa - z < t STATION DEPTH
COMPENSATION INSURANCE ADDRESS C -
(This section need not be completed if the work involved by the �-�– �/" MANHOLE REFERENCE PPER
permit is for one hundred dollars ($100) or less.) LoeaurY c , LOWER
NEAREST --,�, TYPE OF CONNECTION LENGTH FROM r
I certify that in the performance of the work for which this CROSS 5T Y. CURB P.L, M.I,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.C.N0.
I p OWNER '`f CO.IMP.NO. JOE ND. ',"". �"
MAIL
Date Applicant
ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If; after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO DATE
CITY "1 TEL.NO. C
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION Lor NO. HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT /' ,4 STATE ENC
PERMIT NOROACHMENT
LICENSED CONTRACTORS DECLARATION NO. F i
SIZE OF LOT �;.�� NOW ON LOT 7
I hereby affirm that I am licensed under provisions of Chapter
USE OFj
9 (commencing with Section 7000) of Division 3 Of the Busi- BUILDINGS �"" �••-" f`r-�'^' ^ CHARGES
ness and Professions Code, and my license is in full force and
effect J"`i' CONTRACTORS CONNECTION CHARGE FEE
Y
License Number' Lic.Class ADDRESS , REIMBURSEMENT FEE O
!
`+r'�-""�"" '" � DISTRICT NO. GROUP MAP PROCESSED BY V
Contractor - Date v CITY TEL.NO. r.
BK PG / Z
.. r r� •"
❑ I am exempt under Sec. of the L.A.Co. L10ENSTATE 5E No. Y ' CLASS LIC. V�`.
NO. ESCRIPTION OF WORK FEE
Plumbing Code and/Or Sec. Of the HOUSE SEWER CONNECTING TO 4 DA EL VALID "ION W
PUBLIC SEWER
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR VNe �_
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG,OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER G 0 J 7. 8 A
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWEI.L,MANHOLE y a o • 0
Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM d e - 27, 50
}
El 1,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure a 2 7, 5 0 7-
is not intended or offered for sale (Section 7044, Business
and Professions Code), OWNERS I Permit $
0 6 �
ElI, aAUTHORIZATIONs owner of the property,am exclusively contracting with 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
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
OWNERS AGENT
issued (Sec. 3097, Civ. C.), ADDRESS
Lender's Name —
Lender's Address
—
I certify thbt I have read this application and state that the
above in rmation is correct. I agree to comply with all County
oral"an and St laws regulating Plumbing and Sewers,
and he y av oriz representatives Of this County to enter
upon t bq)fe-rner,4ione property for inspection purposes.
gnature of Mittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE