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Home My Public Portal About9165 HERMOSA DR_Sewer__ WORKERS' COMPENSATION DECLARATION I he•eby.oftrim thoi I have a certificate of consent to self 20 M51 DPW 6169 U insure, or a certificate of Workers'Compensation Insurance, or 76A642D Policy Nc !Dpy thereof (Sec. ny lab C.) APPLICATION FOR PERMIT Pally Na_. company SEWER - SEWAGE DISPOSAL ❑ Certilied copy is hereby furnished. , ❑ Certified copy is filed 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' BuILpING y COMPENSATION INSURANCE ADDRESS 65 ^ l-nos r. i9r. STATION J /�� Cf DEPT. (This section need not be completed if the work involved by the LOCALITY Ie. (...0 f I - MANHOLE REFERENCE a ` UPPER permit is for one hundred dollars (5700) or less.) /r� certify that in the performance of the work for which This NEAREST TrPE OF CONNECTION LENGTH FROM CROSS ST. Qhc— "L Y CURB PE ME TOPL permit is issued, 1 sholl not employ any person.in any manner LEGAL 3(Qo PC NO so as to become subject to the Workers Compensation Laws, DESCRIPTION Lor NO. "��I co IMP No JOB No Date Applicant BLOCK TRACT 590 "UNI PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT: If, after making IhiS Cert ifkole O( ASSESSOR AFFIDAVIT NAI Vf4 f45EMENI 4ECORp IN514 NO DATE Q PAGE PARCEL Exemption, you should become subject to the Workers' 1 /tip NO.OF SLDGS. /J Compensation provisions of the Labor code, you must forthwith -11 Tly_ F �L�Js NOW ON LOT 2 .WY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF F -i�Sl 2,tA revoked. BUILDINGS •N W STATE ENCROAC rii NI LICENSED CONTRACTORS DECLARATION PERMIT NO i 1 _Wa� . I hereby affirm that I am licensed under provisions of Chapter owNER�Y1� f Pe"A SOKAzr 9 (commencing with Section 7000) of Division 3 of he Busi- MAIL /`� ADDRESS"E1 6 5 OSX CHARGES ness and Professions Code. and my license is in full farce and L effect. CITY __eM C( TEL N '$ US 2655 CONNECTION CHARGE FEE License Number Lic.Class REIMBURSEMENT FEE CONTRACTOR Contractor Date DISTRICT NO GROUP MAP PROCE55ED BY ADDRESS BK PG ❑ I am >_exem 1 under Sec. of the L.A.Co. ! ' p CITY TEL.NO. ,SDS 3 tart—.IP.a� OF Plumbing Code and/or Sec. oSTATE UC. FINAL ('1 U f the LICENSE NO. CLASS DATE p�'� O,XIDATION Z B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE O�(J f/ � j74 HOUSE SEWER CONNECTING 10 FINAL _ F Date PUBLIC SEWER By K�5{ U SEPTIC TANK SEEPAGE Pit OR .S t!Ei 13 W Signature PITS AND OR DRAINFIELD P OWNER-BUILDER DECLARATION RIVATE SEDISPWER SYSTEM TO ► iU1rL �- - 10 OUSEE EWER CO NECTM I 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 GRAINFIELD C:a?tii'1GE ExTN.CESSPOOL DRYWELL MANHOLE ❑ I,as owner of the property,or my employees with wages as ALTER.REPAIR OR ABANDON.OUSE their sole compensotion, will do the work and the structure SEWER OR DISPOSAL SYSTEM is not intended Or offered for sole (Section 7044. Business 00011--10IIL11 l.:i =/Y9 Q-1and Professions Code). / 7975 1 H!'�j't�:ill '\ I, as ownerthe property, am exclusively contracting with OWNERS Permit $ F5?ii licensed contractors to construct he Protect (Section 7044, Business and Professions Code). AUTHORIZATION TOTAL FEE /. O CONSTRUCTION LENDING AGENCY t HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ONLAACTOR TO 10.I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER for the performance of the work for which this permit Is issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_ OWNER OR Lender's Nome OWNERS AGENT Lender's Address 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 Stole laws regulating Plumbing and Sewers, and her By authorize representatives of this County to enter upon IT,above- I nem rope�or inspection purposes, /Z "Z—SY Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE