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HomeMy Public PortalAbout9410 BLACKLEY ST_Sewer__ WORKERS' COMPENSATION DECLARATION S1 I hereby affirm that I have a certificate of consent to self 111 Insure, or a certificate of Workers'Compensation Insurance, or CE 808 D o certified copy thereof (Sec 3800, Lab C > i E BOB(REV B/B,, APPLICATION FOR PERMIT Policy No Company ©1 . ❑ 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' [NNEAREST DING r . STATION DEPTH COMPENSATION INSURANCE RESSglq (This section need not be completed if the work Involved by the ALITY /E- 7` MANHOLE REFERENCE UPPER permit Is for one hundred dollars ($100)or less ) LOWER I certify that in the performance of the Work for which this / TYPE OF CONNECTION LENGTH FROM S$ST Y CURB P L M L TO P Lpermit is Issued, I shall not employ any person in any manner j Oso as to become subject to the Workers'Compensation Laws NER VA LJ C- / K/IC e- j.-� CO IMP NO TOB rNO� ggL \ TRUNK PERMIT NO ROAD PERMIT NO Date� Applicant .. +� RESS / NOTICE TO APPLICANT If, after m in this Certificate of -r"—/-7,.,-7A, ` ^ AFFIDAVITh WAIVER EASEMENT RECORD INSTR NO DATE g CITY LLT C; EL NO {p I Exemption, you should become subject to the Workers' LEGAL W Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO HWY OR ST WIDENING 0. comply with such provisions or this permit shall be deemed revoked BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO OF PERMIT NO LOT 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 CONNECTION CHARGE FEE effect CONTRACTOR License Number LIC Class ADDRESS REIMBURSEMENT FEE Contractor DateCITY TEL NO DISTRICT NO GROUP MAP PROCESSED BY _ STATE LIC (�? BK PG .., El am exempt under Sec of the L A Co LICENSE NO CLASS � 'c') Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE / �"/Q.r� VALIDATION B & P Code for the following reason PUBLIC SEWER lD 7 SEPTIC TANK SEEPAGE PIT OR FINAL Date PITS AND/OR DRAINFIELD HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR Poo.DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN CESSPOOL DRYWELL MANHOLE 2 5 LI L A Law for the following reason (Secton 7031 5, Buisness and Pro- ALTER REPAIR OR ABANDON HOUSE fessions Code) SEWER OR DISPOSAL SYSTEM o 0,0 0 � Q ❑ 1,as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure 2'a o 2 V$0 is not Intended or offered for sale (Section 7044, Business and Professions Code) OWNER'S Permit g O''0' a 2 5 0 F-11, TOTAL FEE I,as owner of the property,am exclusively contracting with L licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ONTRACTOR TO 0!U 0 6'-8 3 Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCY r I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19S; for the performance of the work for which this permit Is OWNER OR Issued (Sec 3097, Civ C ) OWNERS AGENT ADDRESS e ���' 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/bo property for inspection purposes Sig ure of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE