HomeMy Public PortalAbout10307 KEY WEST ST_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
76A642insure.dr a certificate of Workers'Compensation Insurance, or CE 808
a certified copy thereof (Sec. 3800, Lab C.) CEB�BIREV.,,931 APPLICATION FOR PERMIT «JJ
Policy No. Company
EJCertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. �y /
Date Applicant �iE:w1C.CL�i/�i PEST
FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' STATION ` 2 DEPTH
COMPENSATION INSURANCE J
(This section need not be completed if the work involved by the MANHOLE REFERENCE S UPPEER
permit is for one hundred dollars ($LOO)Of less.) TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this Y. CURB PLM.L.TO P.L.
LD'
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. CO.IMP.NO. JOB NO.
TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ,� ER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of TEL.NO.
Exemption, you should become subject to the Workers' LEGA
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT 36 -235' STATE ENCROACHMENT
NO OF BLDGS. PERMIT NO.
LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF Sl
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
CONNECTION CHARGE FEE
effect. CONTRACTOR
License Number Lic.Class ADDRESS ��L_ S� 4 /��J REIMBURSEMENT FEE
Contractor Date -fi . DISTRICT NO, GROUP MAP PROCESSED BY
CITY �j,TEL.NO. �'rJ /� p(17� BK PG
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. f s— ` CLASS !v" �- �� ®.
NO. DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the FINAL f
HOUSE SEWER CONNECTING TO. DATE .i
B. & P. Code for the following reason PUBLIC SEWER �j. VALIDA N H
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD BV Z
Date HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature CONNECT 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 (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): 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 �3 3 3 6 A
and Professions Code). OWNERS Permit $ �0
❑ I,a's owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE # 0 0 0 0 1 0
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C ACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER,
CONSTRUCTION LENDING AGENCY . 10 - 27.50
1 hereby affirm.that there is a construction lending agency SIGNED THIS DAY OF
for the performance of the work for which this permit is OWNER OR 0 0 0 2 7 5 0 5)
OWNERS AGENT
issued (Sec. 3097, Civ. C.).
ADDRESS 1 0.29-85
Lender's Nome
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
upon bove-mentioned property for inspection purposes. .
Signature at Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE