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HomeMy Public PortalAbout9948 HOWLAND DR_Sewer__ WpR ERS'COMPENSATION DECLARATION he�ebyrAffirm that I have a certificate of consent to self 92.0002 DPW 3/87 irlsure,'ar a.certificate of Workers'Compensation Insurance, or CE 808 76A642D -a certified copy thereof (Sec. 3800, Cly APPLICATION FOR PERMIT Poficy No. Company ¢ ©u. ❑ 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—ApplicantW FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPT FROM WORKERS' BUILDING COMPENSATIO NSURANCE ADDRESS �� � STATION DEPTH (This section need not be completed if the work involved by the y MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY 9 LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS 5T. L/ 61— Y. CURB P.I. M.I.TO P.L. permit is issued, I shall not employ any person in any manner subject to the Workers Compensation Laws. P.C.NO. so as to become sub I p OWNER � v CO.IMP.NO. JOB NO. MAIL Date Applicant ADDRESS �j ,{,(,)(,/� TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, after makingthis Certificate of $ / AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY��L Py � TEL.NO.hlX g3 r 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 ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.SIZE OF 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- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and �.(,� effect. CONTRACTOR /'/ L(a t✓� CONNECTION CHARGE FEE y9g(a3 a 3 �!R License Number Lic.Class ADDRESS Alb ✓k REIMBURSEMENT FEE O ��+/��nq t� O Q) ,a DISTRICT NO. GROUP MAP P CESSED B Contractor Date V () F--�l`' r l CITY TEL.NO. Q/S / BK PG STATE❑ I am ex t under Sec. of the L.A.Co. LICEN q CL ` — 0(�','] LICENSE NO. / (� CLASS l J �' V 0 NO. DESCRIPTION OF WORK FEE L 0 Plumbing Code and/or Sec. of the FINAL W HOUSE SEWER CONNECTING TO DATE VALIDATIO PUBLIC SEWER 41 �-•� B. & P. Code for the following reason / 3 Cl)a SEPTIC TANK,SEEPAGE PIT OR FINAL n PITS AND/OR DRAINFIELD K Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR ► OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, BUISness and Pro- ALTER,REPAIR OR ABANDON HOUSE »1 fessions Code): SEWER OR DISPOSAL SYSTEM ,•_» ❑ I,as owner of the property,or my employees with wages as ;tet( „• their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit $ ITO ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTO -i€-(i_ �F�Business and Professions Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. TCONSTRUCTION LENDING AGENCY d„*7 •I'': L-'-' SIGNED THIS DAY OF 1 I hereby affirm that there is a construction lending agency , r.>_I••-• for the performance of the work for which this permit is OWNER OR � ':?2 =i issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS Lender's Name -,r,f•, _- :< E: Lender's Address M 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 authorize representatives of this County to enter upon the above-menti ned roperty for inspection purposes. �� Sig fure of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE