HomeMy Public PortalAbout9044 HERMOSA DR_Sewer__ � E L
/--Viv6RkeRs, COMPENSATION DECLARATION
here' of I have a certificate of consent to self jl
ipsYre, r Cx&rtificate of Workers'Compensation Insurance, or 76A6°91) u
a ye4trfied copy thereof (Sec. 3800, Lab C.) CESBBIREV.LB31 APPLICATION FOR PERMIT
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
depart ent. �
Date Applicant r .:... - FOR APPLICANT TO FILL IN - ' ' CONNECTION DATA-
C TIFICATE OF EXEMPTION FROM WORKERS' Bmm.NG •,
COMPENSATION INSURANCE ADDRESS �!{� STATION DEPTH
(This section need not be completed if the work involved by the .T 7 MANHOLE REFERENCE UPPER
permit is for one huridred dollars ($100)or less.) LOCALITY _ LOWER
I certify that in the, performance of tha work for which this NEAREST
TYPE OF CONNECTIONLENGTH FROM
CROSS
�� Y. CURB P.L. M.I.TOP,L.
permit is issued, I sholl not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. PC.NO.
OWNER Y� CO.IMP.NO. JOB NO.
Date Applicant
MABRESS. TRUNK PERMIT NO. ROAD PERMIT NO.
'� � - ADD
NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
subjectExemptCITY L NO
Compensat you should become rco . o the Workers' LEGAL
Compensation provisions of s or this code,,you roust forthwith [ADDRESS//
IPTION LOT NO, HWY,OR ST.WIDENING
.comply with such provisions or this perm it•shall,be.deemed ,
revoked. TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.
F LOT NOW ON LOT
I hereby affirm,that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busi- NGS CHARGES
ness and Professions Code, and my license,is in full force and s
effect. RACTOR 6 rl� CONNECTION CHARGE FEE
License Number Lic.Class j REIMBURSEMENT FEE
Contractor Date DlSikfCi NO. GROUP MAP PROLE ED BY BKPGVI am exem t under Sec. of the L.A.Co. Uc ,,,� �00irP E NO. �� CLASS /N•` Vr�/Y DESCRIPTION OF WORK FEE O
Plumbing Code and/or sec. of the FINAL N
HOUSE SEWER CONNECTING TO DATE VALIDAT V
B. 8 P. Code for the following reason PUBLIC SEWER �C- W
SEPTIC TANK,SEEPAGE PIT OR ta.
PITS AND/OR DRAINFIELD FINAL H
Date PRIVATE D SEPOSAAL SYSTEIM i0 BY `
Signature CONNECT ADDITIONAL BLDG,OR -
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's
SEEPAGE PIT,DRAINFIELD ;.2 8 4 9 As License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Sect00 7031.5, Buisness and PFO- ALTER,REPAIR OR ABANDON HOUSE N O'
fessions Code): SEWER OR DISPOSAL SYSTEM M
❑ I,as owner of the property, or my employees with wages as •I ,• • 2 1.50
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 g Q I 2 �,55
v
❑ 1, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 4ZL 5-10 0 9. 04=85
-
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO -
Business and PFOfeSSions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
. CONSTRUCTION LENDING AGENCY ►
I hereby affirm that there is o 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 r
r
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 lows regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
uupp�o-n-�4/)�above-mentioned property for inspection purposes.
.Signature of Permittee -Date SEE REVERSE FOR EXPLANATORY LANGUAGE