HomeMy Public PortalAbout10330 KEY WEST ST_Sewer__ WOf3KBRS"COwPENSATION DECLARATION
I hereby,affirm that I have a certificate of consent to self
insure,.or a certificate of Workers'Compensation Insurance, or 76A642D ll
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. 7// �/J
Date `� y SApplicant •i FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH e
COMPENSATION INSURANCE ADDRESS 'd 6.7 I, 6
(This section need not be completed if the work involved by the LOCALITY L.� MANHOLE REFERENCE ��� LOWER
permit is for one hundred dollars ($100)or less.)
I certify that in the NEAREST TYPE OF CONNECTION LENGTH FROM
y performance of'the work for which this
CROS sr. v. culls 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 Lows. OWNER !'� CO.IMP.NO. JOB NO.
MAIL j'd y,p TRUNK PERMIT NO. ROAD PERMIT NO.
Date - Applicant ADDRESS Gi' f� �V
NOTICE TO APPLICANT: If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CITY TEL.NO.
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT O. HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
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 OF
9 (commencing with Section, 7000) of Division 3 of the.BUST- BUILDINGS ve-
CHARGES
ness and Professions Code, and my license is in full force and .
CONNECTION CHARGE FEE
effect. CONTRACTOR
License Number Lic.ClassADDRESS S� 4 REIMBURSEMENT FEE
Contractor Date L DISTRICT NO. GROUP MAP PROCESSED BY
CITY TEL.NO. �i f •_ BK PG W
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. r.�. CLASS S4�/
9W
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL O
HOUSE SEWER CONNECTING TO ) DATE VALIDA ION
B. & P. Code for the following reason PUBLIC SEWER
PTIC TANK,SEEPAGE PIT OR FINA
PITS AND/OR DRAINFIELD $A
Date HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE
Law 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
their sole compensation, will do the work and the structure ;23329A
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit-, $1 # 0 0 0 0 1 0
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 1 ,27LsO
licensed Contractors t0 construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO RACTOR TO f o,o27.50
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER,
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 1 o 0 o 2 7,5 Qx
v
for the performance of the work for which this permit is OWNER OR N
issued (Sec. 3097, Civ. C.). OWNERS AGENT i Q 2 9 $5
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
upo, above-mentioned property for inspection purposes.
Signature oT Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE