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HomeMy Public PortalAbout9042 ACASO DR_Sewer_10/10/1986_sewer connection WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D a certified cdpy thereof (Sec. 3800, Lab C. CE 808(REV.8/811 APPLICATION FOR PERMIT Policy No. Company ©s ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed if the work involved by the t UPPER permit is for one hundred dollars ($100)or less.) LOCALITY 2 �' MANHOLE REFERENCE LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. CURB P.I. M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Wo s'Cae.,.ti naws. P.C. NO. OWNER � G CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date � ���Applican � ADDRESS / i AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, a ter making this Certificate of CITY TEL.NO. Exemption, you should become subject to the Workers' LEG L Compensation provisions Of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 100 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE @a License Number LIC.Class ADDRESS REIMBURSEMENT FEE O Contractor Date DISTRICT NO. GROUP MAP PROCESSED BY CITY TEL.NO. BK PG El am exempt under Sec. of the L.A.Co. LICENSE NO.TACLASS (J �j /�/j y NO. DESCRIPTION OF WORK FEE r a9 Plumbing Code and/or Sec. of the FINAL VALIDATIONam HOUSE SEWER CONNECTING TO DATE PUBLIC SEWER B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR D .� AI PITS AND/OR DRAINFIELD FINALFILe HOUSE SEWER CONNECTING TO /i PRIVATE DISPOSAL SYSTEM Signature �?y� �/f� //��Z4 CONNECT OAL B& ARWORK OHOUSE E OWNER-BUILDER D ATION OVERFLOW SEEPAGE PIT,DRAINFIELD , I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Sectors 7031.5, BUlsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM 1,as owner of the property,or my employees with wages as // ,1 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S I Permit $ ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION FTOTAL FEE licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACT]TO ;25 6'Q 9 A Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY # ° ° b °•1 O 1 hereby affirm that there is a construction lending agency SIGNED THISDAY OF 1 for the performance of the work for which this permit is OWNER OR If a o 21.50 OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS o o o 2 1,5 0 Lender's Name Lender's Address J 0.,1 0 8 8 6 I certify that I have read this application and state that the ` above information is correct. I agree to comply with all County ordinances a d State laws regulating Plumbing and Sewers, and her y uthorize representatives of this County to enter upon t ove-mentioned rty for i pection purposes.. -/mz, r Lt l Ignature of ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE