HomeMy Public PortalAbout10300 KEY WEST ST_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby'affirm that I have a certificate of consent to self QQII
insure; or a certificate of Workers'Compensation Insurance, or 76A642D U'
a certified copy thereof (Sec. 3800, Lab C. CE808(REV.1/83) 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
department.
Date pplicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING /� C. STATION DEPTH
COMPENSATION INSURANCE ADDRESS FJ � � i
(This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE b q3,31 2Ar6E PIPER
permit is for one hundred dollars ($100)or less.)
I certifythat in the performance Of the Work for Which fh15 NEAREST TYPE OF CONNECTION LENGTHf M
p CROSS ST. Y. CURB P.L. M.I.TO P.I.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. OWNER CO.IMP.NO. JOB NO.
MAIL — TRUNK PERMIT NO. ROAD PERMIT No.
ADDRESS '
Date "Applicant � .
NOTICE TO APPLICANT: If, after making this Certificate of Clty zt TEL.NO. AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR:•NO. DATE
Exemption, you should become subject to the Workers' LEGAL L
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 '3 6 7 5.--
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 Sr CHARGES
ness and Professions Code, and my license is in full force and
- CONNECTION CHARGE FEE
effect. CONTRACTOR
License Number Lic.Class ADDRESS REIMBURSEMENT FEE 10—
Contractor Date n (� DISTRICT NO. GROUP BK MAP PG PROCESSED BY
CITY - r TEL.NO. cam`_ Q
STATE LIC. 0
El am exempt under Sec. of the L.A.Co. ucENSE No. Q/. -2 CLASS `
Rn
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO DATE VALIDATION LU
B. 8 P. Code for the following reason PUBLIC SEWER 16H
SEPTIC TANK,SEEPAGE PIT OR FINAL
Date PITS AND/OR DRAINFIELD FI
HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELO
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secfon 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): D SEWER OR DISPOSAL SYSTEM
❑ 1, 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 7 Permit $ # 0 0 0 0 1 0
❑ 1, as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE
licensed Contractors t0 construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C ACTOR TO I o o27,50
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY SIGNED THIS G OF 19 - 27,505
/ DAY , o
I hereby affirm that there is a construction lending agency -�
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, CIV. C.). OWNERS AGENTe r `' fir/.�/ I 0.29-85
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 authorize representatives of this County to enter
upon bove-mentioned property for inspection purposes.
,> l 9 - P-d5�--`-
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE