HomeMy Public PortalAbout5407 WELLAND AVE_Sewer__ ;► / KERS' PENSATION DECLARATION 920002 DPW 3%87 w1
here�a ff1°m't I have a cerlificote of consent to self 74A642D
tifiatire, o�
-
ce t te of Workers'Compensation Insurance, or
a certified c herec-(Sec. 3800, 'ab C.) CF 808 APPLICATION FOR PERMIT
Policy N•' f �mpany � Cas SEWER
rfified copy is hereby furnished. ER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Applicant , , ' ._ FOR APPLICANT TO FILL IN CONNECTION DATA
f CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING J
COMPENSATION INSURANCE ADDRESS STATION DEPTH
(This section need not be completed if the work involved by the MANHOLE REFERENCE UFP
permit is for one hundred dollars ($100)or less.) LOCALITY a N ER
NEAREST ,�. /. a TYPE.OF CONNECTION LENGTH FROM ,6
I certify that in the performance of the work for which this CROSS ST. • d y,I CURB P , M-L.TO P.L. 5 "
permit is issued, I shall not employ any person in any manner P C.NO.
so as to become subject to the Workers'Compensation Laws. OWNE f ?�... --y,- CO.IMP.NO, JOB NO, 3-`J-
MA.IL .`� j - TRUNK.PERMIT NO. ROAD PERMIT NO
Date Applicant ADORES .
1
NOTICE TO APPLICANT: If, after making this Certificate of CITY p TEL ° r^°-a s P' f 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
revoked. BLOCK TRACT &' STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF LOT PERMIT No
SIZE OF LOT ���Q .: �
I hereby affirm that I am licensed under provisions of Chapter NOW ON LOT !r,tlf r` t °
usE aF t
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS yr .' 3 ? CHARGES "
ness and Professions Code, and my license is in full force and a
effect. de.-y CONTRAC,TOR �--C-- =t`--,e-,z_.�_„ C - CONNECTION CHARGE FEE
License Numbe y - _. LiC.Class C ADDRESS REIMBURSEMENT FEE p-
;� ( DISTRICT NO GROUP MAP PROCESSED By Q
Contractor ,✓ Vii'6� Date "` CITY TEL.NO.
STATE -�p •�` UG BK PGS/
El am exempt under Sec. of the L.A.Co. LICENSE No. t CI ASs
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Plumbing Code and/or Sec. of the NO.J DESCRIPTION OF WORK FEE FINAL w
HOUSE SEWER CONNECTING TO :�"� , - DATE VALIDA ON
Q
PUBLIC SEWER
B. & P. Code for the following reason. S/?
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD
Date HOUSESEWER CONNECTING TO
`-- PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that 1 am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE ) }8 (` t
Law for the following reason (Sectors 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
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 ( 7 v :a
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $ 75 C
I, as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE !r.
licensed contractors to construct the project (Section 7044, 0 7L7 ? 8
I HAVE AT THIS GATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR Toll"
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
OWNERS AGENT
issued (Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
Lender's-Address
I cert fy 'tha ave read this application and state that the
abo Irhfarmat' n Is correct I agree to comply with all County
ord naQVs an State laws regulating Plumbing and Sewers,
an by eby authorle representatives of this County to enter
t.U on 1 e above-m ntioned property for inspection pure s.
t ignatu Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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