HomeMy Public PortalAbout8919 HERMOSA DR_Sewer__ WORKERS' COMPENSATION DECLARATION SEI
4 hgreby affirm that I have or certificate of consent to self. .20'0051 DPW 6189 u
Insure-, al o certificate of Workers'-Compe nsb lion Insurance, or 76A6420
a Penr:,ed copy (hereof (Sec. 3800, lob C.) APPLICATION FOR PERMIT
Po IiCX No. Company SEWER - SEWAGE DISPOSAL
❑ Certified copy is hereby furnished.L1 Certified Certified copy is Bled with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY '
department.
Dole Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING C STATION DEPTH
COMPENSATION INSURANCE ADDRESS u//
This secnon need nor be completed If the work involved b the UPPER
( P Y MANHOLE REFERENCE (OWER
permit is for one hundred dollars ($1D0) or less.) LOcqurr
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that In the performance of the work for which this CROSS ST. Y CURB PL ML TOP(
permit is issued, I shall not employ any person in any manner 'ECAC PC rya
so as to become subject to the Workers' Compensation Laws. LEGAL PC LOT No, co IMP NO '05 110
Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
ASSESSOR ` p 'y AIFIDAVIT WAIVER EASEMENT RECORD (NEER NO DATE
NOTICE TO APPLICANT: If, alter making this Certificate of YEARBOOK ,/�Q PAGE le 1 PARCEL(/d(/
Exemption, you should become subject to the Workers'
NO.oOeLDcs.
Compensation provisions of the Labor code, you must forthwith SIZE OF Lor NOW ON LOT Hwv oRST wioeryl.NG
comply with such provisions or This permit shall be deemed USE OF
revoked. BDILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION ' PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter t
WNER
9 (commencing with Section 7000) of Division 3 of the Busi- AIL ` CHARGES
DDRESS
ness and Professions Code, and Fri license is in full forte and r�r�
effect. ITY U� �+ TEL.NO. CONNECTION CHARGE FEE
License Number LIC Class CONTRACTOR (97L-1'/[/p � � REIMBURSEMENT FEE
�
Contractor-Date DISTRICT NO GROUP MAP A
ADDRESS �j PG }❑ am exempt under Sec. of the L.A.Co. art rEl.No. .OQ /�3 ICE
O
Plumbing Code and/or Sec. of the STATE tic. FINAL U
LICENSE No, CLASS DATE VALIDATION Z
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE 0
HOUSE SEWER CONNECTING 10 nrygL H
Dale / PUBLIC SEWER By W
SEPTIC TANK SEEPAGE PIT OR a
PIIS AND OR DRAINFIELD F f
Signature Z {
OWNERBUILDERDECLARATION HOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM
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 - - -•
fessions Code): OVERFLOW SEEPAGE Pit DRAINFIEID -'-- )_
EKTN,CESSPOOL.DRYWELL MANHOLE -
❑ I, as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE
their sale compensation, will do the work one the structure SEWER OR DISPOSAL SYSTEM -7i .r
is not intended or offered for sale (Section 7044, Business
and Professions Code). =,HECK 72.-2D
I os owner of the property, our exclusively contracting with %�r- -
licensed contractors to construct the project (Section 7044, OWNERS Permit S Z t.;;t?f'{_;(_ ,)Jii
Business odd Professions Code). AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING) AGENCY I HAVE At THIS DATE A CONTRACT WITH THE HEREIN NAMED ,CNIRACIOR TO {') I II ;;�fj lllC
I hereby affirm that there IS a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING D'NEWNG TO THE PUBVC SEWER , :)'-1�.�f-1 L�_il _; y_ - .
for the performance of the work for which this permit Is ,4 � :,:...( {e`_
issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF I9_ '
OW ryER OR
Lender's Name 0111NER5 AGENT
Lender's Address ADDRESS
I certify that I hove read this application and state that the
above information is correct. I agree to comply with oil 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.
tilure of Permit a Dote SEE REVERSE FOR EXPLANATORY LANGUAGE