HomeMy Public PortalAbout9014 ACASO DR_Sewer_7/12/1970_Connect addl bldg to house sewer 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 copy thereof (Sec. 3800, Lab C.) 92-0002 DPW 6/88
APPLICATION FOR PERMIT
Policy No. Company
❑ 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 /1 /(1 (� �YJ STATION DEPTH
COMPENSATION INSURANCE ADDRESS (�
(This section need not be completed if the work involved by the LOCALITY j 1 MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOWER
I certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
CROSS ST.
V. CURB P.L. M.L.10 P.L.
permit is issued, I shall not employ any person in any manner P.C.NO.
so as to become subject to the Workers'Compensation Laws. OWNER CO.IMP.NO. JOB NO,
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
AFFIDAVIT I WAIVER EASEMENT RECORD,INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.No.
Exemption, you should become subject to the Workers' LEGAL
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
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 CL0
License Number Lic.Class ADDRESS REIMBURSEMENT FEE U
W
Contractor Date DISTRICT NO. GROUP MAP PROCESSED BY J
CITY TEL.NO. BK PG LL.
El am exempt under Sec. of the L.A.Co. LICENSE NO.TACLASS >_
NO. DESCRIPTION OF WORK FEE Irf
Plumbing Code and/or Sec. of the F1NAL <
HOUSE SEWER CONNECTING TO DATE VALIDATION
B. 8 P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR CL
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY W
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's license OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions 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). OWNERS Permit $
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ,
I 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 OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT
ADDRESS
Lender's Name
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 the above-mentioned property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE