HomeMy Public PortalAbout10324 KEY WEST ST_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self j�
insure, or a certificate of Workers' Compensation Insurance, or /eAa42D U
a certified copy thereof (Sec. 3800, Lab C. CE808(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
Da �
plicont a�s�-- FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION �i DEPTH
COMPENSATION INSURANCE ADDRESS (J y
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPP
permit is for one hundred dollars ($100)or less.) LOCALITY _ WEIR
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. v. cuRe P.L. M.L.TO P.L.1>
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws. P.B NO.
I P OWNER - CO.IMP.NO. !OB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS a
NOTICE TO APPLICANT: If, after makin this Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
g CITY TEL.NO.
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 ENCROACHM NT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.
SIZE OF LOT NOW ON LOT
I hereby affirm that.I am licensed under provisions of Chapter usE OJdAtNF
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 r REIMBURSEMENT FEE
ny / DISTRICT NO. GROUP MAP PROCESSED By
Contractor Date CITY �VIL TEL.NO. C/ BK PG
STATEE� LIC.
El am exempt under Sec. of the L.A.Co. LICENSE NO, R� CLASS -` �-- �� ✓ �'
PlumbingCode and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL /// n
HOUSE SEWER CONNECTING TO DATE � /�/ VALIDATfON
B. & P. Code for the following reason PUBLIC SEWER ate/ BM
SEPTIC TANK,SEEPAGE PIT OR M
PITS AND/OR DRAINFIELD FIN 41111
Date HOUSE SEWER CONNECTING TO 7.
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR loop.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 3 3 3.8 A
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure # 0 0 0 0 Q
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit $
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION I 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 0 U
CONSTRUCTION LENDING AGENCY . i
I hereby affirm that there is a construction lending agency SIGNED THIS Y OF 29-85
for the performance of the work for which this permit is OWNER OR Q
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 t above-mentioned property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE