HomeMy Public PortalAbout10319 KEY WEST ST_Sewer__ D
WOkKERS'COMPENSATION DECLARATION
I hereby affirmWhaf I have a certificate of consent to self
insure, or—a certificate of Workers'Compensation Insurance, or 76A642D )I
'a—`certif ed copy thereof (Sec. 3800, Lab C.) CE 808(REV.1/83) APPLICATION FOR PERMIT
Policy No. Company
p❑ Certified copy is hereby furnished. SEWER SEWAGE DISPOSAL
J Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES -BUILDING AND SAFETY
' ` department. �y / __��
Date�(�D pplicant Z.- �1� /d FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
S STATION I I DEPTH A
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the LOCALITY �� MANHOLE REFERENCE v y LOWER
permit is for one hundred dollars ($100)Or less.) 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
P.C.NO.
SO as to become subject to the Workers'Compensation Law S. OWNER �`S GD /YjY CO.IMP.NO. JOB NO.
MAIL - TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS `
NOTICE TO APPLICANT: If, after making this Certificate of CITY �E AFFIDAVIT 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 (o STATE ENCROACHMENT
PERMIT NO.
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS.
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the BUST- BUILDINGS S CHARGES
ness and Professions Code, and my license is in full force andj `f
effect. CONTRACTOR ` CONNECTION CHARGE FEE _
License Number LIC.Class ADDRESS ^ �L REIMBURSEMENT FEE
Contractor DateCITY TEL.NOUC
DISTRICT NO. GROUP MAP PROCESSED BY
.
STATE _ r BK PG
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. Ap, a' CLASS
151" R 3
, A/ 0
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WK FEE FINAL
HOUSE SEWER CONNECTING.TO DATE VALIDAT N a9
B. & P. Code for the following reason PUBLIC SEWER !/ �
SEPTIC TANK,SEEPAGE PIT OR FINAL
Date PITS AND/OR DRAINFIELD FI
,51
BY
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 (Sectors 7031.5, BuisneSs and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM 2 33 2 8 A
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the Structure # o,0 0 0'�
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $ 1 o - 27.50
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 2 7 5O 5
ro on
PI ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
licensed contractors to construct the project (Section 7044, o 0 0
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY / Q 2 9'-$5
I hereby affirm that there is a construction lendOWNER
lending agency SIGNED THIS DAY OF !/ 19 ►
for the performance of the work for which this permit is OWNER
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-mentioned property for inspection purposes.
Signature of Permittee SEE REVERSE FOR EXPLANATORY LANGUAGE
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