HomeMy Public PortalAbout8927 HERMOSA DR_Sewer__ WORKERS' COMPENSATION DECLARATION
I herebri affirm that I have a certificate of consent to self Q
r gnsur^ea certificate of Workers'SZaLnpensation Insuronce, or TeAeazD III
a certified copy thereof(Sec. 3800, Lab C.) CE 808(REV,,,B]I APPLICATION FOR PERMIT Il
Policy No. Company
❑ 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' BUDDING f /j'l $ STATION 2,QL/ DEPTH 6
COMPENSATION INSURANCE /
(This section need not be completed if the work involved by the LOCALITY '/]f 1 ••� MANHOLE REFERENCE /�,6 T AlN 6;`L UPPER
permit is for one hundred dollars ($100)or less.) LOWER
that in the erformance of the work for which this NEAREST TYPE OF CONNECTION MA.TO FROM
I certif
Y P CROSS Si. T. CURB P.L. LEN TO P.l.
permit is issued, I shall not employ on pers //II a y manner ^
so as to become subject to the W r i C E a i a�w�s�.�•v� OWNERAap $l ,!/yL'/ CO.IMP.No. JOB No,
MAILDate Applicant waw ADDRESS (/�C(i jG� I/� TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, ager making this Certificate Of // AFFIDAVIT WAIVER EASEMENT RFCORD.INBTR.NO. DATE
CITY / TEL NO. (p _
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROAC MENT
LICENSED CONTRACTORS DECLARATION �y' ra.OF eLOGs. Z— PERMIT NO.
SIZEOFLOT ® NOW ON LOT2
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 7— CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR t ��� ° CONNECTION CHARGE FEE
License Number Lic.Class ADDRESS /• REIMBURSEMENT FEE d
Contractor Date ) O 4 /_ / DISTRICT NO. GROUP BK MAP � ZIR� IFD SEDY V
CITY TEL NO. </J Y
❑ I am exem t under Sec. of the L.A.Co. STATE yT LIC. t e C
P LICENSE NO. ( CLA55 /���1
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL �� V
HOUSE SEWER CONNECTING TO DATE VALID ION W
B.'& P. Code for the following reason PUBLIC SEWER -7 (J h
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR ORAINFlELD
FIN - Z
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
hereby affirm that I am exempt from the Contractor's License OVERFLOW SPPLRE..COO,SEEPAGE
MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Ode): SEWER OR DISPOSAL SYSTEM ffff*pffff }(AL�
as owner of the property, or my employees with wages as 1 4 1217,8 V
their sole compensation, will do the work and the structure 1 e e J ll
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit S e o 0 2 7,, r0 Q 5i
❑ 1, as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE Q IL2 2 —8 6
licensed contractors to construct the project (Section 7044, 1 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 ouch irl7f, r presentatives of this County to enter
;pa tv a ed
rope
for inspection purposes.
SiSignatureW6rimiltee �^y ` Date SEE REVERSE FOR EXPLANATORY LANGUAGE