HomeMy Public PortalAbout5561 WELLAND AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I he,R+,y offi;oo that I have a certificate of consent to self a
insure, or a certificate of Workers'Compensation Insurance,or 76A642D
a certified copy thereof (Sec. 3800, Lab C. C_E808IREv ;re, APPLICATION FOR PERMIT
Policy No. Company SEWER - SEWAGE DISPOSAL
El Certified copy is hereby furnished.
❑ Certified copy is filed with the courtly building inspect'
COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
i
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS _ siniloN I 7= DEPTH
(This section need not be completed if the work invr -,d byth LOCALITY MANHOLE REFERENCE a �Gf f 0 UPWE
permit is for one hundred dollars ($100)or less.t NEAREST TYPE OF CON LENGTH FROM
I certify that in the performance of the wr r which th CROSS ST _ '42°'
Y CURB P.I, M L TO P.L.
permit is issued, I shall not employ any un in any manrer No
so as to become subject to the Worke, ' _ompensation laws. OWNER / CO.IMP NO. !OB NO.
MAIL _ f�,,.,?T TRUNK PERMIT NO. ROAD PERMIT NO.
Dote Applicant _ ADDRESS
.
NOTICE TO APPLICANT: If, after making this Certificate of CITY
WAIVER EASEMENT RECORD,INSTRNO. DATE
rY.r'� _ rr, ���, r
Exemption, you sho-'i become subject to the Workers' LEGAL
`omperTsahon 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 PSTATE ERMIT NO.OACHMENT /t
LOT
LICENSED CONTRACTORS DECLARATION NO of B (�
SIZE OF TOT 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 Code, and my license is in full force and ,
'" r CONNECTION CHARGE FEE
effect. CONTRACTOR
License Number Lic.Class ADDRESS f y 1 REIMBURSEMENT FEE d
y/ 1� . DISTRICT NO. GROUP MAP PROCESSED BY O
Controctor�- •F Date CITY TEL NO. " �`' PG U
STATE - LIC.
El (_I 6 ,j g / � Q
I am exempt under Sec. of the L.A.Co. LICENSE No. LIC, x`- (�
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL V
-HOUSE SEWER CONNECTING TO �" DATE..f ,. 1 VALIDATI N W
B. 8 P. Code for the following reason PUBLIC SEWER i �_ h
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL / Z
" - HOUSE SEWER CONNECTING TO FI // '
PRIVATE DISPOSAL SYSTEM
Signature 1 4 f CONNECT ADDITIONAL BLDG.OR
,A6WNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT DRAINFIELD
I hereby offirfti that I am exempt from the Contractor's License EXTN,CESSPOOL,DRYWELL,MANHOLE
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
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit $
49'
El 1,I,as 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 Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY
SIGNED THIS DAY OF 19'`
I hereby affirm that there is a construction lending agency — - 2750x
for the performance of the work for which this permit is OWNER OR ,. v
P P
issued (Sec. 3097, Civ. C.). OWNERS AGENT r •j I �
ADDRESS d !, ��G ..�
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereEiy Uthorize represe 10tive5 of this County to enter
upgn.tve-mentioned o erty for inspection purposes.
S' noture of Permittee Date f SEE REVERSE FOR EXPLANATORY LANGUAGE