HomeMy Public PortalAbout10306 KEY WEST ST_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 11
insure, or a certificate of Workers'Compensation Insurance, or 76A642D U
a certified copy thereof (Sec. 3800, Lab C.) CE808(REV.1/B3) 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&=,��Applicant T_7 t /����i FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by theLocALITY 9 MANHOLE REFERENCE 3 3 ' UPPE R
permit is for one hundred dollars ($100)or less.) TYPE OF CONNECTION
NEAREST LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner P.C.NO.
so as to become subject to the Workers' Compensation Laws. owNER ,, CO.IMP.NO. JOB NO.
MAIL /., �,iCJ• 'J�(..�-` TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CITY 711—1 TEL.NO.
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT O. 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 f I /
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 5` CHARGES
ness and Professions Code, and my license is in full force and /
effect. CONTRACTOR ✓ J CONNECTION CHARGE FEE
License Number LIC.ClassADDRESS 94�>77
REIMBURSEMENT FEE
Q� DISTRICT NO, GROUP MAP PROCESSED BY 06
Contractor Date
CITY TEL.NO. Q BK PG 0
❑ I am exempt under Sec. of the L.A.Co. LICENSTATESE
req CL �",f'y aY
P LICENSE NO. CLASS "�6�� f
C�
NO. DESCRIPTION OF WORK FEE L O
Plumbing Code and/or Sec. of the HOUSE SEWER CONNECTING TO /� DATE VALIDATION
B. & P. Code for the following reason PUBLIC SEWER (J
SEPTIC TANK,SEEPAGE PIT OR J �
PITS AND/OR DRAINFIELD FIN
HOUSE SEWER CONNECTING TO BY
Date
PRIVATE DISPOSAL SYSTEM
SignatureCONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK To HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Sectors 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Cade): SEWER OR DISPOSAL SYSTEM
❑ I,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 Permit $ IQ L2 23 3 a 0 A
❑ 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 CONTRACTOR TO # O O O 0'1 0
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY G�^-f— I o o27.50
I hereby
affirm that there is a construction lendingagency SIGNED THIS DAY OFOWNER
for the performance of the work for which this permit s OWNERSOAGENT � o o,0 2 7.5 0 cit
issued (Sec. 3097, Civ. C.). 029-85
ADDRESS
Lender's Name
Lender's Address
I certify that I have read this.application and state that the
above information is correct. 1 agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
�the bove-mentioned property for inspection purposes.
.,7 r ��
Sign Lure of Permittee, Date SEE REVERSE FOR EXPLANATORY LANGUAGE