HomeMy Public PortalAbout9932-9934 WOODRUFF AVE_Sewer__ 76A642D APPLICATION FOR PERMIT
WORKERS'COMPENSATION DECLARATIQ,_N CE 808 (2 80) SEWER-SEWAGE DISPOSAL
I hereby affirm that I have a certificate of consent to self BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or COUNTY OF LOS ANGELES
a certified copy thereof(Sec. 3800,Lab C.) CONNECTION DATA
ij 7 Company f ,.J�:r /
Policy No FOR APPLICANT TO FILL IN �
/ DEPTH
D �, STATION � (3�,.S
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Certified copy is hereby furnished. BUILDING 1 ✓ r,'., t r--�`•. q J j
ADDRESS .�°Lv ,-"1' II � �
MANHOLE REFERENCE LOWER
Certified copy is filed with the county building lnspehYtQn fee`,r LENGTH FROM
LOCALITY /'/ TYPE OF CONNECTI
department. r C ..
Y. CURB 5 P L. M.L. 70P
>A / '' Applicant, a' ... @@@@��� NEAREST v
DatC�---s:---- CROSS .ST. °�+ ) P.C. NO.
CERTIFICATE OE k XEMPTION FROM WORKERS' p A. gI + JOB No.
' .��- CO, IMP. NO.
COMPENSATION INSURANCE rOWNER �, > = /t ROAD PERMIT NO. ] � 0.
. - TRUNK PERMIT NO. ///9�,a .lf l DATE� `�' `� L'- AFFIDAVIT WAIVER EASEMENT RECORD.IN5TR.NO. 0(This section need not be completed if the work involved TEL. NO ',.by the permit is for one hundred dollars ($100) or less.)I certifv that in the performance of the work for which this 2 HWyY OR ST. WIDENING O
person in any manner DESCRIPTION LOT NO.
permit is issued, I shall not employ any p
STATE ENCROACHMENT LU
so as to become subject to the Workers' Compensation Laws. BLOCK TRACT PERMIT NO. a
NO. OF BLD GS.
Date Applicant '
SIZE OF LOT CHARGES NOw oN Lar _, 2
e
NOTICE TO APPLICANT: If, after making this Certificate of USE OF
Exemption, you should become subject to the Workers' BUILDINGS
CONNECTION CHARGE FEE
Compensation provisions of the Labor Code, You must forth.-
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with comply with such provisions or this permit Shall 1)e CONTRACTOR f I ,' � ) REIMBURSEMENT FEE
deemed revoked. /cf �I ', 1r r i .�,+ MAP PROCESSED BY
ADDRESS DISTRICT NO. GROUP PG
LICENSED CONTRACTORS DECLARATION t e c g
CITY / -�' a TEL. NO
I hereby affirm that 1 am licensed under provisions of Chapter ue. I 3 ,•—s
9 (commencing with Section 7oo0) of Division 3 of the Busi- STATE y `s�" eLwss
ness and Professions Code, and my license is in full farce and LICENSE NO. VALIDATION
NO, DESCRIPTION OF WORK FEE FINAL
'ffect. HOUSE SEWER CONNECTING TO DATE
WI `. ! S PUBLIC SEWER _
License Number
Lic.Class SEPTIC TANK,SEEPAGE PIT OR FINAL
P5T8 AND(OR GRAINFIELD
r/ - r r... Date - BY r
ontractor HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLOC.OR V
1 am exempt from the licensing requirements as I am a
�.l 0
professional engineer WORK TO HOUSE SEWER
licensed architect of ii registered p OVERFLOW SEEPAGE PIT,DRAINFIELO
nal capacity (Section 7051, BUS E,XTN.,CESSPOOL,DRYWELL,MANHOLE
acting in my p
rofeSSlo
iness and Professions Code), ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
j
i,ic.or Reg.No. Date i
HOME:OWNER-BUII,DER DECLARATION Permit s
OWN E R'S
,
hereby affirm that I am exempt from the Contractor's AUTHORIZATION TOTAL FEE
icense Law for the following reason (Section 7031.5, Blasi-
less and Professions Code)' 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON' L
'IRA CTOR TO CONN F.CT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
„
I, as owner of the property, will do ttie work and the Dqv OF 19
structure is not intended or offered for sale (Section SIGNED THIS
OWNER OR
7044, Business and Professions Code). OWNERS AGENT --
CONSTRUCTION LENDING AGENCY ADDRESS
hereby affirm that there is a construction lending
X nit gencis
or the performance of the work for which this pe
ssued(Sec. 3097,Civ.C.)•
vender's Name
,ender's Address
certify that I have read this application and state that the
above information is correct.I agree to comply withal(S wens,
)rdivances and State laws regulating Plumbing
I
d hereby authorize representatives of this County to enter
pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE.
,Pon tZI "atlove- entione.4 property for ins
Date
Signature of Permittee