HomeMy Public PortalAbout8925 HERMOSA DR_Sewer__ / WORKERS'COMPENSATION DECLARATION
r he%Rby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or vagaesD
a certified copy thereof (Sec. 3800, Lob G) EEgas,REV.B,Bt, APPLICATION FOR PERMIT
Policy No. Company �s
❑ 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 p c�� f STATION S9, " DEPTH
COMPENSATION INSURANCE ADDRESS O ✓ P.
(This section need not 6e completed if the work involved by the LOCAUT MANHOLE REFERENCE ��� Q' .�/ PPeR
permit is for one hundred dollars ($100)on less.) - LOWER
1 certify that in the performance of the work 4a which this Ca055S9T TYPE OF co ION LENGTH FROM
T. NR t P.L. M.I.TO P.L.
permit IS ISSUEd, shall not employ any person in any manner _ P.0 NO.
50 a5 t0 become subject to the Wo er5 O e ti Laws._ OWNER ZMY CO.IMP.NO. l00 NO.
L
Date Applicant ADDRESS �.L TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after makin t is Certificate of / Q/ 5/�/ AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.No. DATE
g CITY TEL.NO, OLa
Exemption,- you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR Si.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION sONLLO
PERMIT NO.
SIZEOFLOT NOW s
I v F
hereby affirm that I am licensed under provisions of Chapter uBE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS Il CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR CONNECTION CHARGE FEE r
License Number LIC.Class ADDRESS 9 y 1011Z REIMBURSEMENT FEE O
.moi DISTRICT NO. GROUP MAP PROCESSED 8Y V
Contractor P Date CITY ZLEL NO. 6 e� �P`/ ✓/ (' BK PG O
❑ I am exempt under Sec.-of the L.A.Co. STATE ..//)) Q �/�J( UC. �y i3
LICENSE NO. J J ! `JJ J CLASS S 9
OV
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK NE FINAL V
HOUSE SEWER CONNECTING TODATE _ VALID .ION d
PUBLIC SEWER
B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR Z
PITS AND/OR DRAINFIELD RNA
Dote HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM % I
Signature CONNECT ADDITIONAL BLDG,OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractors License ExTN_YESSFOOL,DRYwELL,MANHOLE'
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
feBs,3 ode): 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). OWNER'S Permit
❑ I, as owner of the property, am exclusively contracting with - AUTHORIZATION TOTAL FEE o2
licensed contractors to construct the project (Section 7044, I 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 uthor' r r sentatives of this County to enter
upon t ab e- en a pro er y for inspection purposes.
'Signature oMignmittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE