HomeMy Public PortalAbout10240 DAINES DR_Sewer__ WORKERS' COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self 20A0051 DPW BT89 . FIJI
insure, or a certificate of Workers' Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C.) AATIO FOR �LR�I�
Pohjy No. Company m i P! N RM
❑ 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 JILL 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 MANHOLE REFERENCE �� f��, y� C� QPPP
permit is for one hundred dollars ($100) or less.) LOCALITY LOWER
I Certlf that in the performance Of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
Y P CROSS ST. y
permit is sued, 1 shall not employ any person in y manner CURB P L M L ro P L
LEGAL PC NO:
SO OS t0 eC0 e sub' ct to the Workers' Compensa Ion Lows. DESCRIPTION LOT NO. CO IMP NO JOB NO
Date Applicant 7� . BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO PPLICANT: If, after makingthis Certificate of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOOK PAGE PARCEL
Exemption, you should become subject to the Workers' NO.OF BLOGS.
Compensation provisions of the Labor code, you must forthwith h SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT No
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL CHARGES
ADDRESS
ness and Professions Code, an�Lic.
�/license is in full force and
effect. /_J/�(�. CITY CONNECTION CHARGE FEE
License NumbZ CONTRACTO ClassAtev REIMBURSEMENT FEE
Contractor ate DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS � � BK PG
El am exempt under Sec. of the L.A. Co. �`pt�j � Q ,f/ >_CITY (�d :J �Y � a
Plumbing Code and/or Sec. of the STATE LIC. FINAL V
LICENSE NO. CLASS DATE ��,J� Q� VALIDATION O
B. & P. Code for the followingreason NO. DESCRIPTION OF WORK FEE ` ((,� __d Z
HOUSE SEWER CONNECTING TO FINAL
Date PUBLIC SEWER / BY V
SEPTIC TANK SEEPAGE PIT OR W
Signature PITS AND OR DRAINFIELD
MOUSE SEWER CONNECTING TO
OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM =- z
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR -
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT.DRAINFIELD
feSSIOnS Code): EXTN,CESSPOOL.DRYWELL,MANHOLE
❑ I, as owner of the property,Or my employees with wages as ALTER REPAIR OR-ABANDON HOUSESEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure ? _._.._
is not intended or offered for sole (Section 7044, Business �
and Professions Code). OT L 66 ` •••••+
❑ 1, as owner of the property, am exclusively contracting with L =a
licensed contractors to construct the project (Section 7044, OWNERS Permit $ '.•i"s='�•": ---••=
Business and Professions Code). AUTHORIZATION I TOTAL FEE.
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WIT THE HE IN N ED TRACTOR TO
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTIN DwELw To rH UC SEWER
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). SIGNED THIS OF III 9_ _``1''„1 5UE•;T_1 r _3+:••_
OWNER OR
Lender's Name OWNER AGENT
f, h
Lender's Address ADDRESS
I certify that I h e read this application and state that the
above informa ” n is correct. I agree to comply with all County
ordinances d tate laws re ati Plumbing and Sewers,
and hereb ut rize repr entativ f t County to enter
upon th ov -mentione pr foin ion purposes.
Signature of Perm tee Dat SEE REVERSE FOR EXPLANATORY LANGUAGE