HomeMy WebLinkAbout1592A (9)WORKERS' COMPENSATION DECLARATION
1 hereby,offirm that I have a certificate of consent to self
'insure, or a certificate of Workers' Compensation Insurance, or
o certifiedco thereof (Sec. 3800, Lab
Policy No.Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection
de t�L n��,,""
DoteF 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 sholl not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
prion, you should become subject to the Workers'
ipensotlon provisions of the Labor code, you must forthwith
—m ply 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
Controctor FL_Jr IFE�Dote
❑ I am exempt under Sec. of the L.A. Co.
Plumbing Code and/or Sec. of the
B: 8 P. Code for the following reason
Dole
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
low for the following reason (Secton 7031.5, Buisness and Pro -
ions Code):
JI, as owner of the property, or my employees with wages os
their sole compensation, will do the work and the struclure
is not intended or offered for sole (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 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,
and hereby authorize representatives of this County to enter
upon theabove-mentioned property for inspection purposes.
211�1
Signature of Parmittee . Date
76A64M
CE We (REV. B/81) APPLICATION FOR PERMIT
�r SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
CONNECTION DATA
eURDING D
R
STATION
DEPTH
ADDREss
LOCALITY i
MANHOLE REFERENCE
'- UPPER
LOWER
NEAREST O
TYPE OF CONNECTION LENGTH FROM
CROSS ST. ...J
Y. CURB
P.L. M.L. TO P.L.
RIC. NO,
OWNER Lv
CO. IMP, NO.
JOB NO.
MAILQ
TRUNK PERMIT NO.
ROAD PERMIT NO.
ADDRESS EJ O
AFFIDAVIT WAIVER EASEMENT RECORD INSTR, NO, DATE
CITY (1y E�e4 � TEL NO.
LEGAL
DESCRIPTION LOT NO.
HWY. OR ST. WIDENING
BLOCK TRACT to
STATE ENCROACHMENT
PERMIT NO.
NO. OF BIDGS.
SIZE OF LOT NOW ON LOT
USE OF
CHARGES
BUILDINGS
CONTRACTOR
CONNECTION CHARGE FEE
ADDRESS -
REIMBURSEMENT FEE
A
DISTQICT NO,
GROUP
MAP
PROCESSED 9Y
CITY lEl. t•10. d
� 6
SK PG
STATE �/ LIC.
LINO. /[ CLASS
QNSEVn?
NO. DESCRIPTION OF WORK FEE
FINAL
DATE
VALIDATION
HOUSE SEWER CONNECTING TO FU
PUBLIC SEWER
^ Z
sFPi1C TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD
FINAL
9Y
40,
D
t10USE SEWER CONNECEING TO
PRNATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG, OR
WORK TO HOUSE SEWER
WERFLOW SEEPAGE PT, DRAINFIELD
EXTN , CESSPOOL. DRYWEIL MANHOIE
-
15 9, F
ALTER. REPAIR OR ABANDON HOUSE
SEWER ORaISPOSAL SYSTEM
„.
1-27.50
OWNER'S Permit s (o '7
AUTHORIZATION TOTAL FEE j0
... 2 7.5 0 u
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
y.� pp ((��
9. `
CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. �/
HIS
SIGNED TDAY F�_190.
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O LJ 2 C. V
DINNER IN
OWNERS AGENT
�L
F�
ADDRESS
..
SEE REVERSE FOR EXPLANATORY LANGUAGE
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