HomeMy Public PortalAbout10311 KEY WEST ST_Sewer__ WORKERS' COMPENSATION DECLARATION \
I hereby affirm that I have a certificate of consent to self
'insure, dr a certificate of Workers'Compensation Insurance, or 76A642D U
a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.1/83) APPLICATION FOR PERMIT
Policy No. Company
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
[Certified copy is filed with the county;M:Z
COUNTY OF LOS ANGELES BUILDING AND SAFETY
"I department.
Date Applicant 3� FOR APPLICANT TO FILL IN CONNECTION DATA y
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING — r / STATION DEPTH /!
COMPENSATION INSURANCE ADDRESS &1!
(This section need not be completed if the work involved by the MANHOLE REFERENCE 31 31 UPPER
permit is for one hundred dollars ($100)or less.) LocnuTv R
NEAREST TYPE OF CONNECTION 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
so as to become subject to the Workers' Compensation Laws. OWNER , �, CO.IMP.NOP.C.No.
. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEI
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
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 512E OF LOT NOW NO.OFO'III
LBLDGOTS. PERMIT NO.
en gait
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 / CONNECTION CHARGE FEE
License Number Lic.Class ADDRESS ¢ REIMBURSEMENT FEE
Contractor Date .� DISTRICT NO. GROUP MAP PROCESSED BY
CITY TEL.NO. BK PG
STAA LIC.
❑ I am exempt under Sec. of the L.A.Co. LICENSE No. aCLASS �� � ✓JVL bTb
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO DATE
AT VALIDAT N
PUBLIC SEWER
B. 8 P. Code for the following reason
SEPTIC TANK,SEEPAGE PIT OR FIN
PITS AND/OR DRAINFIELD Q!y
Date HOUSE SEWER CONNECTING TO BY /
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 33 3.5 A
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 S # o 0 0 0 Q
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE I o o27,50
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. O O O 2 7.5 O CJ
CONSTRUCTION LENDING AGENCY ,p� Q o 9-13 5
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 1
for the performance of the work for which this permit is OWNER
OR ��
issued (Sec. 3097, Civ. C.). OWNERS AGENT
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 the above-menti ed property for inspection purposes.
Sign of Permi a Date SEE REVERSE FOR EXPLANATORY LANGUAGE