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Home My WebLink About1238A (6)WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or .7 U20 acertifitgd„ppy tbptgo'3BQprap'bmCont .Indemnity O,SW `pE". B'B"APPLICATION FOR PERMIT .. Policy N P ❑ Certified copy is hereby, furnished. - _ -. SEWER - SEWAGE DISPOSAL Certlfied cox is filed with the county 'Iding inspecti In r 1•4 Q COUNTY OF LOS ANGELES BUILDING AND SAFETY deWicb6i 6 RCR By / Date Applicant (IJ -44 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 WorkersCompensation Laws. gyp•—��eApplicant f 'ICE TO APPLICANT: If, after making this Certificate of `L.emption, you should become subject to the Workers' Compensation 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 336428 C-36 License NuRIf, c. Clgs�16J86 Contractor Dofe ❑ 1 am exempt under Sec. of the L.A. Co. Plumbing Code and/or Sec- B. ecB. & P. Code for the following reason FOR APPLICANT TO FILL IN CONNECTION DATA A DORFSSSS 24427 E. Gold o in t 1 e STATION DEPTH LOCALITY Diamond BST MANHOLE REFERENCE UPPER L R NEAREST - TYPE OF CONNECTION LENGTH FROM CROSS ST. Y. CURB P.L. M.L. TO P.L. No OWNER salith Gniintry rnrp CO. IMP. NO. JOB NO. �oI fe AD MAILSS P.O. • O . BOX 3329 TRUNK PERMIT NO, ROAD PERMIT NO. ' ! Covina CoV 818-967-9541 AFFIDAVIT WAIVER EASEMENT RECORD, INSTR. NO. DATE CITY lnaT I LEGAL their sole compensation, will do the work and the structure DESCRIPTION - LOT - HWY. OR ST. WIDENING BLOCK TR i A Is not intended or offered for sale (Section 7044, Business STATE ENCROACHMENT SLOW PERMIT NO. SIZE OF LOT OW ON LOT and Professions. Code). USE OF Residential- %� BUILDINGS BUILDINGS ❑ I, as owner of the property, am exclusively contracting with CHARGES CONTRACTOR (j CONNECTION CHARGE FEE ADDRESS rtUMbingt Inc licensed contractors to construct the project (Section 7044, REIMBURSEMENT FEE VE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR 10 DISTRICT NO. GROUP MAP PROCESSED BY CITY TEL. IN �-Y BA PIS STATE LIC. ! y LICENSE NO. CLASS SIGNED THIS DAY OF NO. DESCRIPTION OF WORK FEE FINA•— HOUSESEWERCONNECTINGTO /!7 DATE /r/ VALIDA ON PUBUC SEWER _ / J SEPTIC TANK. SEEPAGE PIT OR FINAL PITS AND/OR DRAINFLELD HOUSE SEWER CONNECTING TO BY Y F M PRIVATE DISPOSALSYSTEM ADDRESS a V OWNER -BUILDER DECLARATION WORK O Hain SEWER OVERFLOW SEEPAGE Pit. DRAINFIELD ^Eeby affirm that l am exempt from the Contractor's license -rAUTHORIZATION ExrN.. CESSPOOL, DRYWTU. MANHOLE ( tfor the following reason (Secton 7031.5, Buisness and Pro- ALTER, REPAIR OR ABANDON HOUSE tesslons Code): SEWER OR DISPOSAL SYSTEM ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure Is not intended or offered for sale (Section 7044, Business and Professions. Code). Permit s . OWNER'S Q %� --I p o7, v Q ❑ I, as owner of the property, am exclusively contracting with TOTAL FEE (j s R - 2 7 6 0 cS licensed contractors to construct the project (Section 7044, VE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR 10 -- Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING OWEtUNG TO THE PURI C SEWER - CONSTRUCTION LENDING AGENCY 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 OWNEROR issued (Sec. 3097, Civ. C.). OWNERS AGENT " Lender's Name ADDRESS - - Lender's Address - - - I certify that I have read this application and state that the above information is correct. I ogre& to comply with all County - - - ordinances and Stale laws regulating Plumbing and Sewers, andhereby authorize representatives of this County to enter - - - - g Inspy_c! 1T1ehgsabov 1nentione `.P t f itl+Siiggnatturre��of ' Permiltee DateO - SEE REVERSE FOR EXPLANATORY LANGUAGE .. - INSPECTOR'S NOTES OWNER -BUILDER DECLARATION APPROVALS DATE _ INSPECTOR'S SIGNATURE NEW HOUSE SEWER CONFECTADOInONAt - f SUKD'N OR WORK AM AM/OR DRA WIWLO TIS) OESSPOOL 0 ORYWEEL ❑ ALM, REPAW SEWER OR SEWAGE aSPOSAE arsrEAt 04SCONr4CT 0.LH, ANO AaAPAOH NOVSE SENOR _- ._ EAC.L SEPTIC TANKS Q SEEP, PIT S O CESSPDOts ❑ --- I hereby affirm that I am emmpt from the Contractor's License Law for the following reason (Section 7031.5, . - Busmen , a -d Prgenioms Codek Amy city or county wbicb. isquiaes a'permit to construct, niter, improve, der tolfb, or repair any structure, prior to its itsmonce, . - also requires the appllm-t Jor srcb pan -it to file a signed stafa-amt that beis tiered punant to the propitious of the Comtrucfor's Lkmm Iaw (Cbapter 9 - - (commencing with Sectio- 7000) of Divition 3 of the Business and Professions Cade) or Met be is @"mpt - . therefrom end the bati s for the alleged aremphou. Amy violation of section 7031,5 by any appNeatt fora permit subjects for applicant to a civil penalty of"* more than five hundred dollort 18500%: 111, as the owner of the property will do the w, and the structure is not intended or offered for eek. . (Sec. 7044, Bnsimen and Profaetio-s Cade 72_iC. tractor's License Low does mot apply to on owasr of property wbo be" or improves tbrreon, and wbo doss such wort bimwlf provided that smeb improvemauts are not intended or offered for sale. If, bowaver, the boUding or improvement is said witbin one year of _ ... completion, the moor -builder will beve the burden of proving that be did not build or improve for the purpose of sale.! I am exempt under Sec. , B & P.C. for this reason �. �... - Date Owner INSPECTOR'S NOTES - .. .