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HomeMy Public PortalAbout9227 WORKMAN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION 1 herby affirm that I have a certificate of consent to self 92-0002 DPW s 0� .Isu 'P a certificate of Workers'Compensation Insurance, or rtAEazD a cer.stled copy thereof (Sec. 3800, Lob C.) CE BOB APPLICATION FOR PERMIT Policy No. Compony _ t©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 _Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' FNEAR srnnon DEPTH COMPENSATION INSURANCE (This section need not be completed if the work involved by the •' MnNHole REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY y �'� LOWER ,�3 TVPf OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this Y. CURB PL. M.L.TO P.L. permit is issued, I s all note any person in q y manner so as to ec b"ect t e Wor rs'Com en n=n L n P C.NO. �' _ 'L P OWNER �MAIL „:�f ,d `.�L.' CO.IMP,NO. JOB NO, '� ._l - ” ADURE$S �/� Q.; �L YL9 r-ryry ?RUNK PERMIT NO, ROAD PERMIT NO. Date Applicant AFFIDAVIT WAIVER EASEMEfJT RECORD.INSTR.NO. DATE NOT,CE TO APPLICANT: If, after making this Certificate of CITY eP" - -e TEL.NO. vo 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 BLDG$ 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 CONNECTION CHARGE FEE License Number Lic.Class ADDRESS REIMBURSEMENT FEE +J Contractor Dote DISTRICT NO. GROUP MAP PROCESSED BY ) CITY TEL.NO. BK PG -, STATE LIC. - ❑ 1 am exempt under Sec. of the L.A.Co. _t P LICENSE NO. CLASS 1 Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE J FINAL ,, _ HOUSE SEWER CONNECTING TO i. °} DATE J G.. 6 Y VALIDATI B. 8 P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR C FINAL PITS AND/OR DRAINFIELD ,._. Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM G• L--7 Signature CONNECT ADDITIONAL BLDG.OR , OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fesS(oCode): SEWER OR DISPOSAL SYSTEM pll�l as owner of the property, or my employees with wages as 5 74 A their sole compensation, will do the work and the structured p 1 0 is not intended or offered for sale (Section 7044, Business apol Professions Code). OWNERS Permit I, as owner of the property, am exclusively Contracting with AUTHORIZATION TOTAL FEE `� , licensed COnlraCi015 f0 construct the project (Section 7044; I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO y y 2l 5 0 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY 010. {� 1. , 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 issued (sec. 3097, Civ. C.). OWNERS AGENT ADDRESS Lender's Nome 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, an reby authorize represen fives of this County to enter Upon t above-mention erty for InS urposeg, Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE