HomeMy WebLinkAbout1774A (10)f/ WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self
insure, or a certificate of Workers' C ensation Innsnce, or
a certified pv f (Sec. 3800. ab
Policy No Company.
Certified copy is hereby furnished.
DateCer
fi copy is filed with t county bu' ing inspectin
Applicant W I
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 ($100) or less)
I certifv that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Bust-
ness and Professions Code, and my license is in full force and
effect.
3r
Licensee NNuu mberr;g/
l/
7, J Lic. Class
p/(
ConifJCfflrf_1
F11 am exempt from the licensing reyuireWents as I am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
Lic. or Reg. No. Date
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
El1, as owner of the property, will do ttie work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is.
issued (Sec. 3097, Civ, C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. 1 agree to comply with all County
ordinances and St to taws regulating Plumbing and Sewers,
and hereby autt nee representatives of this County to enter
upon,{hy abov Ventioned property for inspectj$n-ggrposes.
ign e f Permittee 458tee
CE808 2-8D) APPLICATION FOR PERMIT
SEWER—SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING i, y G STATION DEPTH
ADDRESS 460 ;j
I
MANHOLE REFERENCE
UPPER
LOCALIT/,/ Y r rG LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
CROSS ST. Y. CURB P.L. M.L. TO P. 1.
P.C. NO.
OWNER ` / CO. IMP. NO. Jos NO.
MALL
ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO.
Q
Fvinavi 1NI sE. coRD. I sT . 10.
1
11re
CITY TEL. l l Sf'V
LEGAL /
D ESCRIPTIOry LOT NO.
HWY. OR ST. WIDENING
BLOCK TRACT STATE ENCROACHMENT
NO. OF BLDGS.
PERMIT NO.
S12E OF LOT NOW ON LOT
USE OF
BUILDINGS CHARGES
1JJWJ CONNECTION CHARGE FEE
CONTRACTOR
1/ REIMBURSEMENT FEE
ADDRES J rri7F
lgTR.<T N RD Da MA. .D
PRD Es,ED .,
STATE LIC.I.t i 0LICENSENO. cA 55
DESCRIPTION OF WORK FEE
HOUSE 59WER CONNECTING TO FINAL VALIDATION
dE DTEA
IT IR
ND(oN D
FINAL
TO
G. DR 100
ALTER, REPAIR 11 .—E
BY
rr
OWNER'S I Permit s Q
AUTHORIZATIONTOTAL FEE
z1774A
1 1.11 11 T.15 11T1 I C*NTI.ITEA•Dve DeaeR I.E. II
T. THE P__ SEWER. # • • • • 1 D
SIGNED THIS DAY OF I9
NER..GE 1 --17,50
1750om
0308-82
SEE REVERSE FOR EXPLANATORY LANGUAGE
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