HomeMy WebLinkAbout2346AWORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self
insure, or O. certificate of Workers, Compel cation Insurance, of
a cenified copy thr c600, Labe/ Party N
0 Ci rtih c o F
Certified copy is filed with the butcfinqttibn
deportment. -
Dale__ApptitontCERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not.be completed if theworkinvolved by the
permit.is faone hundred: dollars:(SIODj"or )
I. certifythat in the -performance -of the work farwhichthis
permit is issued,_I $_hall not employ onypersan in any manner
so as to become subject to the Worke ' Compensation Lows.
Date Applicant
NOTICE TO _APPLICANT; If.. after -:=king..rhis :Certificate of -
Exemption, you should became subject to the Workers'
Compensation provisions of the Labor code; you must forthwith
comply with such provisions or this permit shalt be deemed
revoked. -
LICENSED CONTRACTORS DECLARATION
I -hereby affirm that f 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 NumberEic. Class
ILA&Co o - _—_----Date
I am exempt under Sec. of the L.A. Co.
Plumbing Code and/or Sec. of the
B. & P, Code for the following
Signature -
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Low For the following reason (Secton 7031.5, Buisness and Pro-
fessions Code):
1:11, as owner of the prop", or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered fa sale (Section 7044, Business
and Professions Code).
I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 704.
Business and Professions Code}
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work fa which this permit is
issued (Sec, 3097, Civ. C.).
Lender's Name
76A612D
CE MIT f5mV. 1183; APPLICATION .FOR PERMIT
SEWER • SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDINGADDRESS fSTATION DEPTH
LOCALITY t
UPPERMANHOLEREFERENIZ
LOWER
NEAREST TYPE OF CONNECTION LENGTH FROMCROSSST. Y. CURB P.L. ML. TO P.L. -
OWNER P.C. NO.
Ca. IMP. Na !OB No.
MAILADDRESS TRUNK PERMIT NO. ROAD PERMIT NO.
AFFIDAVIT WANER EASEMENT RECORD, INSTR. NO, DATE
CITY NO.
LEGALDESCRIPTION LOT NO. MwY. OR ST. WIDENING
BLOCK TRACT NATE ENCROACHMENT
NO, OF SLOGS. PERMIT NO.
SIZE OF LOT NOW ON LOT
USE OFBUILDINGS - - CHARGES
CONTRACTOR - ' lMj CONNECTION CHARGE FEE
r . Af)DREss - -.. 4f"y- REIMBURSEMENT FEE22,/f- wcrry1_1 TEL N OD / ry 2
DISTRICT NO. GROUP AW PaaCE55ED Br
C. LICENSE
BK
NO. 7l C-0011
N10- RIPTIONOFWEMK TEF
rV
PUBLIC SEWERmCONNECTING To nNAkDATE CI ` a % VALIDATION
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/O¢ORAINFIELD- .. FINAL
HOUSE SEWER CONNECTING TO BY
PRWA DISPOSALAONTCONNECTTOHOUSE SE E BLDG. ORWORKCTHOUSESEWER
OVERFLOW SEEPAGE PIt, DIUMNIF FLD
FXTN, CESSPOOL DRYWELL MANHOLE
TER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAIL SYSTEM
OWNER'S Permit s
AUTHORIZATION TOTAL FEE
L HAVE AT THIS DATE A CONTRACT WITH TfE iEREIN NAMED CONTQACTO. TO 2 3 Q 6 A
CONNECT THE ABOVE DESCRIBED EXISTING DWELLII* TO THE PU&iC SEWER.
SIGNEDTHIS DAYOF 19_
OWNER OR
OWNERS AGENT
ADDRESS
Lender's Address -
1 certify that i have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and Stole lows regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the oboe entioned propert inspection purposes.
Sig"s, a of Pwminee to SEE REVERIE FOR EXPLANATOW LANGUAGE
10
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