HomeMy Public PortalAbout9924-9926 WOODRUFF AVE_Sewer__ WORICERS'COMPENSATION D1`CL.ARATION* 4J61A642Dr `
CE 808 (2..80) ~APPLICATIC71`� FOR PERMIT
1 hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insure„ or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(See- 3800,Lab.4-,) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No'."`''t �`/ �� Company I ° . _�. " r,ti f
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA
.BUILDING :. „ �. 1,... STATION DEPTH
ADDRESS
Certified copy is filed with the county uilding inspect on y
department. p' !
LOCALITY MANHOLE REFERENCE of9�'S 'tr r L
R
Date; Applicant _ c ON L
y
.�.�f OWER
- � NEAREST r —� TYPE OF CTI ENGTH FR M
CERTIFICATE OF EXEMPTION FROM WORKERS' cRosS sr. Ham' _ :<r` _ Y. CURB P.L.
COMPENSATION INSURANCE s P.C. NO.
OWNER , ,• �' ,ti'... �. f CO. IMP,NO. i JOB NO.
MAIL , }
(This section need not be hundred
if the N9vork Involved ADDRESS ';e �( �; +,, `s�f ( � 1�.� (�-('d a TRUNK. PERMIT NO. ROAD PERMIT NO.
by the permit is for one hundred dollars ($100) or less.) fF AFP'#DAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE 0
CITY a t ,C; 4' <-�YEL. NO.,n 1•�, �� ip f Fd,
I certify that in the performance of the work for which this LEGAL I
permit is issued, I shall not employ any person in any mariner DESCRIPTION LOT NO.
HWY. OR ST. WIDENING
so as to become subject to the Workers'Compensation Laws. �
BLOCK TRACT STATE ENCROACHMENT
LLI
Date Applicant NO. OF BLDGS. PERMET NO. Q-
NOT'ICE. TO APPLICANT: If, after makingthis Certificate of slzE of Lor NOW ON LOT ,% �
Exemption, you should become subjecto the Workers' USE OF
BUILDINGS CHARGES
Compensation provisions of the Labor Code, you must forth-
with Comply with such provisions or this permit shall be CONNECTION CHARGE FEE
coNrRAcroR
deemed revoked.
LICIiNSED CONTRACTORS DECLARATION ADDRESS REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter p.. + E f f.. DISTRICT NO. GROUP MAP PROCESSED BY
9 (commencing with Section 7000)of Division 3 of the Aust- CITY (;'� f r TEL. NO, p" g;' r SK / PG
ness and Professions Code, and my license is in full force and LICENSE NO. ��? �a' _CLASS
effect. NO. DESCRIPTION OF WORK FEE
11U1E SEWER CONNECTING TO
- FINAL VALIDATION
License Number Lic,Clays PUBLIC SEWER DATE
SEPTIC TANK"SEEPAGE PIT OR _
^` : PITS ANDJOR DRAINEIEL.
Contractor .° r,:el Date ,#f Ja 4 FINAL
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM BY
I am exempt from the licensing requirements as I am a
CONNECT ADDI'YIO NAL BLDG.OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting in my professional capacity (Section 7051, Bos- OVERFLOW SEEPAGE PIT,DRAINFIELD
iness and Professions`,ode). ExTN.,CESSPOOL,DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic.or Reg,No, Date
HOME OWNER-BUILDER DECLARATION _
I hereby affirm that I am exempt from the Contractor's OWNERS Permit S
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATIONI TOTAL FEE
ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
® TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ,
1, as owner of the property, will do the work and the TO THE PUBLIC SEWER.
structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19
7044, Business and Professions Code). OWNER DR
OWNERS AGENT
CONSTRUCTION LENDING AGENCY ADDRESS
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C:.).
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 law, regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE:
Signature of Permittee 11%," Date