HomeMy Public PortalAbout10318 KEY WEST ST_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a-certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C.) CE808(REV.1/63) APPLICATION FOR PERMIT Illi
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
dep�t0ment. P 1 =� l�
Date (/ v�c�10LYgZ A licant 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 the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY _ OWER
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 mann—
so
NO.
r
so as to become subject to the Workers'Compensation Laws. OWNER CO.IMP,NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO, DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO.
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT N 11 HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemedr-
revoked. BLOCK TRACT STATE ENCROACHMENT /J
LICENSED CONTRACTORS DECLARATION SIZE OF LOT NNOOW.OF ON LOT LOTE'LDGPERMIT NO. 7
I hereby affirm that I am licensed under provisions of Chapter TSE 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 T REIMBURSEMENT FEE 06
Cantfactaf Date / DISTRICT NO. GROUP MAP PROCESSED BY O0
CITY TEL.NO. �b BK PG
❑ I am exempt under Sec. of the L.A.Co. LICENSE
t C�j 9- f CLLIC {J�J Ay
P LICENSE NO. 9J r1C `'{O —CLASS e—4-L
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL
OUSE SEWER CONNECTING TO DATE ' / VALIDATI N
B. & P. Code for the following reason PUBLIC SEWER 06 l
SEPTIC TANK,SEEPAGE PIT OR FINA
PITS AND/OR DRAINFIEID BY
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
❑ I,as owner of the property,or my employees with wages as ;9 3 3 1L O A
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business # 0 0 0 0 1 O
and Professions Code). OWNER'S Permit $
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE a I ° o27,50
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTR CTO- TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. o - 27.506
CONSTRUCTION LENDING AGENCY e
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF t1 , 10,291-85
for the performance of the work for which this permit is OWNER OR
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 t bove-mentioned property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE —