HomeMy Public PortalAbout8807 HERMOSA DR_Sewer__ WORKERSCOMPENSATION DECLARATION
hereby,affirm that I have a certificate of consent to self 20 0051 DPW 6169
nsd'rc; or a certificate of Work,i Compensation Insurance, or 76A6420
a certified copy the.egf 3800. `ad C.
Pahcy N°. Company , APPLICATION FOR PERMIT'. ❑ 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 EXEMP71ON FROM WORKERS' BUT ED'
NG
COMPENSATION INSURANCE ADDRESS �p0 G• STATION DEPTH
This section need nor be completed If the work involved b the UPPER
( p y LOCALITY MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
CROSS ST. y CURB PL "I FORT
permit is issued. I shall not employ any person In any manner
GAL PC NO
50 CTS 1° become subject t0 the Workers' Compensation LOWS, DESCRIPTION LOT NO, CO IMP NO JOB NO
Dale Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT' If, after makingthis Certificate of ASSESSOR O �{,p� AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOOK O PAGE O�� PARGELf/✓ /
Exemption, you should become rcode, o the Workers' NO.OF BLDGs.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE of
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION � PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER ��$ ■� �-9E�
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL0 '� Z��F1j'hup Try ( CHARGES
E .
nes, and Professions Code, and my' license is in full force and ADDRESS
effect. CITY TNO. 9ro * 3 CONNECTION CHARGE FEE
License Number— Lic, Class REIMBURSEMENT FEE
CONTRACTOR
Contractor Dote DISTRICT NO GROUP MAP PROCE66ED BV
ADDRESS BK PG
Elam exempt under Sec. of the L.A.Co. f,—CITY TEL.NO0�' Ii /�_� � 0.
Plumbing Code and/or Sec. of the STATE CFINAL 0
LICENSE NO. CLASS
SS DATE VALIDATION Z
B. 8 P. Code for The EOliOwtn9 reason NO. DESCRIPTION OF WORK FEE O
HOUSE SEWER CONNECTING TO FINAL f
Date PUBLIC SEWER BY 0
SEPTIC TANK SEEPAGE PIT OR W
Signature PI'S AND OR GRAINFIELD �!t CL
OWNERBUILDERDECLARATION HOUSE SEWER CONNECTING TO , ., s Z
PRIVATE DISPOSAL SYSTEM
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
LOW for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER E;_ =t-lx .�
fessions Code DRAINHELD '-
Ex1N.CESSPOOL DRYWELL MANHOLE
F T
1 3 r -=
EI 1, REPAIR OR ABANDON HOUSE
I, as owner of the property,or my employees with wages as J
their sole compensation will do the work and the structure SEWER OR GlsPasAl SYSTEMcf-I = 5
is not intended or offered for sale (Section 7044, BusinessIHL
r:L__ r 1:77
and Professions Code). ._;,t7�41\ .._
❑ I, as owner of the property,am exclusively contracting with Permit $ Q t_i�H1Y_ ol_1Lt
licensed contractors to construct the project (Section 7044, OWNER:$
Business and Professions Code), AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING SWELLING 10 THE PUBLIC SEWER WOO -011,0
for the performance of the work for which this permit is
issued (Sec 3097, Civ. C. SIGNED THIS DAV OF 19_
OWNER OR
Lender's Name OWNERS AGENT
Lender's Address 0ADDRESS
I certify that I have read chis application and state that the
above information is correct. I agree to comply with all County
ordinances and State lows regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-onntioned property for inspection purposes.
Signature of Permittee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE