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HomeMy Public PortalAbout10312 KEY WEST ST_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby)�affirlm that I have a certificate of consent to self insure,'or a certificate of Workers'Compensation Insurance, or 76A642D p 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 building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. ' r DateApplicant a FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING �"� STATION' DEPTH COMPENSATION INSURANCE ADDRESS (ij / y 19 400_ (This section need not be completed if the work involved by the �� lJ MANHOLE REFERENCE L' / 1 PPER permit is for one hundred dollars ($100)or less.) LOCALITY 6 6 31 Low R NEARESTTYPE 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. v cJ' ���� P, NO. I P OWNER CO.IMP.NO. JOB NO. MAIL =i TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS a3 NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE t CITU TEL.NO. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOTHWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed C revoked. BLOCK TRACT S STATE ENCROACHMENT 4 11A LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. / PERMIT NO. SIZE OF LOT NOW ON LOT VV • 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 Q© r CONNECTION CHARGE FEE License Number Lic.Class ADDRESS r REIMBURSEMENT FEE Contractor Date / ® DISTRICT NO. GROUP MAP PROCESSED BY 0 CITY TEL.NO. _ 4 Q /� gK PG ❑ I am exem t under Sec. of the L.A.Co. STA ULASS C. P LICENSE NO. C Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE B. 8 P. Code for the following reason PUBLIC SEWER 0 VALIDA ION 0. SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD BY 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 Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ;2333 !1 9 n El 1,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure # o ° o 0 1 Q is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ Q ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE ° ° 2 7,5 licensed contractors 10 construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON RACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. o o - 27,506 CONSTRUCTION LENDING AGENCY Q , I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF ®G 19 V ( 0,29-85 OWNER OR for the performance of the work for which this permit is OWNERS AGENT issued (Sec. 3097, Civ. C.). 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 above-mentioned property for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE `