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HomeMy WebLinkAbout0497AWORKERS' COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec, 3800, Lab C.) Policy No. Company ❑ Certified copy is hereby furnished. © Certified copy is filed with the county building inspection department. / Date Applicant_ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed If the work involved by the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: if, offer making this Certificate of Exemption, you should become subject to the Workers' CompensotTon provisions of the Labor code, you must forthwith comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that i am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and effect, License Number Lic. Class Contractor ❑ I am exempt under Sec.— Plumbing Code and/or Sec. Dote B. 8 P. Code for the following reason Signature the L.A. Co. of the OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Secion 7031.5, Buisness and Pro- fessions Cade}: ❑ I, as owner of the property, or my employees with wages as their sale compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 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 laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the obove-mentioned property for inspection purposes. Signature of Permittee Date )6A6420 d' CE 8011 (REV. 8/BI, APPLICATION FOR PPMIT ' ®, SEWER - SEWAGE DISPOSAL COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING STATION DEPTH ADDRESS LOCALITY MANHOLE REFERENCE UPPER LOWER NEAREST TYPE OF CONNECTION LENGTH FROM CROSS ST Y. CURB P.L. M.L. 70 P.L. RC NO OWNER CO. IMF. NO JOB NO. MAIL TRUNK PERMIT NO ROAD PERMIT NO. ADDRESS AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO DATE CITY TEL Na I LEGAL HWY. OR ST. WIDENING DESCRIPTION LOT NO STATE ENCROACHMENT PERMIT NO .�- BLOCK TRACT NO OF BLDGS. SIZE OF LOT NOW ON LOT USE OF CHARGES BUILDINGS CONTRACTOR CONNECTION CHARGE FEE ADDRESS REIMBURSEMENT FEE DISTRICT NO GROUP MAP PROCESSED BY CITY TEL. NO. BK PG STATE LIC LICENSE NO. CLASS NO DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE VALIDATION PUBLIC SEWER SEPTIC TANK. SEEPAGE PIT OR PITS AND 'OR DRAINFIELD FINAL BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM - , CONNECT ADDITIONAL BLDG OR WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT, DRAINFIELD c EMN., CESSPOOL. DRYWELL, MANHOLE ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM - OWNER'S Permit $ AUTHORIZATION TOTAL FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER SIGNED THIS DAY OF 19_ ► OWNER OR'rZjC,.; OWNERS AGENT ADDRESS SEE REVERSE FOR EXPLANATORY LANGUAGE