HomeMy Public PortalAbout10336 KEY WEST ST_Sewer__ WORKERS'COMPENSATION DECLARATION
1 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. CE 808(REV.1/831 APPLICATION FOR PERMIT
Policy No. Company
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the c qty building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. 1-1
Date iApplicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' FADDRESS115
l/'P STATION +S1 DEPTH
COMPENSATION INSURANCE 1 VLA(This section need not be completed if the work involved by the MANHOLE REFERENCE / UPP Rpermit is for one hundred dollars ($100)or less.) Z�' �� �� hI WER
NEAREST TYPE OF CONNECTIONLENGTH FROM
I certify that in the performance of the work for which this CROSS ST. (b Y. CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner P .NO.
so as to become subject to the Workers'Compensation Laws. OWNER CO.IMP.NO. JOB NO.
MAIL O TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of c1rY , TEL.No. AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT O. HWY.OR$T.WIDENING
comply with such provisions or this permit shall be deemed �✓
revoked. BLOCK TRACT (c> PSTATE
ERMIT NO.OACHMENT
LICENSED CONTRACTORS DECLARATION NO,OF BLDGS.
I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE 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 'IRci � REIMBURSEMENT FEE
Contractor Date CITY TEL.NO. 0.
;Ae/ ✓l 6 7 DISTRICT NO. GROUP BK MAP PROC ED BY 0
PG
STATE LIC. % In 99
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. ,�.` CLASS 6=• �. �•
O
OF-WORK FEE b
Plumbing Code and/or Sec. of the NO. DESCRIPTION FINAL ^ VALIDATI N
HOUSE SEWER CONNECTING TO DATE
B. 8 P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR 11 04
6!9
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY
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 ^ :0 3 3 31 A
their sole compensation, will do the work and the Structure
is not intended or offered for sale (Section 7044, Business # o o o 0 1 0
and Professions Code). OWNERS Permit $
❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 1 o o 27.50
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ``/' o 0 0 27.505
1 herebyaffirm that there is a construction lending agency SIGNED THIS AY OF 6
9 9 Y , I
for the performance of the work for which this permit is OWNER OR a 2 9=85 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
Upoa above-menti ned property for inspection purposes.
Signature o Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE