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HomeMy Public PortalAbout5562 WELLAND AVE_Sewer__ �—' -,,R)W<ER9''J,OMPENSA'1IoSN bECLARATION I .hereby dffirm thdt I hove a certificate of consent to self insure, or d certificate of Workers'Compensation Insurance, or 76A642D a certified cop jjth�e.r"eof (Sec. 3800, Lab C.l CE BW(REV.8/81) APPLICATION FOR PERMIT Policy-No. .— Company ;,6MA, FA-fl D ®s ❑ 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–t"--Q—Applicant Sc y? ./r"/�l.� FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' fBLDINGCOMPENSATION INSURANCE DRESS srnrioN DEPTH (This section need riot be completed if the work involved by the if MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) ALITY LOWER I Certl# that in the er#ormance of the work for WhICh this REST TYPE OF CONNECTION LENGTH FROM Y p SS ST. permit is issued, I shall not employ any person in any manner Y. CURB P.I, M.L.TO P.L. so as to become subject to the Workers'Compensation Laws. �j P.C.NO. OWNER G v ae Q CO.IMP.NO, JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO, Date Applicant ADDRESS _ NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.lNSTR.NO. DATE CITY TEL.NO. a 4 Exemption, you should become subject to the Workers' LEGAL «� Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO d HWY.OR 5T.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT - STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. 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 Code, and my license is in full force and effect. CONTRACTOR "• `i0 4 CONNECTION CHARGE FEE > License Numberqi_F61 Lic.Class ADDRESS a REIMBURSEMENT FEE O Contractor DOLE l f /1 p DISTRICT NO. GROUP MAP PROCES 0 BY u CITY 7 l_ iEL NO L` ° //�� 8K PG } Z ❑ I am exempt under SEG. of the L.A.Co. STATE NO CASs l51 V A� 6 O 0 Plumbing Code andU ,or Sec. of the NO. DESCRIPTION Of WORK FEE PUFIN VALIDATION OW. HOUSE SEWER CONNECTING TO B. & P. Code for the following reason BLICSEWER , 0 Z SEPTIC TANK,SEEPAGE PIT OR FINA PITS AND/OR DRAiNFIELD - Date HOUSE SEWER CONNECTING TOBY ` ,A PRONATE DISPOSAL SYSTEM SignatureCONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER Gw l I hereby affirm that I am exempt from the Contractor's License EO TN.,CCESSPOOL,SEEPAGEPIT, Law for the following reason (Secton 7031.5, BulsneSS and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Cade): SEWER OR DISPOSAL SYSTEM ,fes ❑ I,as owner of the property,or my employees with wages as 8, 25 their sole compensation, will do the work and the structure m ,E is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ 2"a AUTHORIZATION i ❑ I,as owner of the property, am exclusively contracting with TOTAL FEE a U licensed contractors to construct the project (Section 7044, I 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 AGENCYZ z , I hereby affirm that there is a construction lending agency SIGNED THIS AY OF t for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT' D:�j ADDRESS ,[,�_ 7i?/'lam �� / LJ�— y©•� 'x: \ Lender's Name \\VM 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 hereby authorize representatives of this County to enter upon t e abovniianedperTy f spection purposes. v` ce r� 1 Signa re of Permiffee Date SEE REVERSE FOR EXPLANATORY LANGUAGE