HomeMy Public PortalAbout10342 KEY WEST ST_Sewer__ • WORKERS'COMPENSATION DECLARATION.
I hey by affirm that I have a certificate of consent to self i1
Sinsgure, or a certificate of Workers'Compensation Insurance, or 76A642D U
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.
Date/ Applicant �.• '�j�i/ FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGSTATION �` DEPTH
COMPENSATION INSURANCE ADDRESS !D �. 1J
(This section need not be completed if the work involved by the LOCALITY
' MANHOLE REFERENCE �c �PW
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.I.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. n ✓� P.C.No.
I P OWNER CO.IMP.NO. JOB NO.
MAIL �> TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS L�
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' LE AL �f
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 ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF LOT PERMIT NO.
SIZE OF LOT NOW ON LOT g
I hereby affirm that I am licensed under provisions of Chapter us E OF Q
EIR
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 s�
CONNECTION CHARGE FEE
effect. CONTRACTOR
License Number Lic.Class ADDRESS 4 REIMBURSEMENT FEE
Contractor DateDISTRICT NO, GROUP MAP PROCESSED BY
CITY TEL.NO. BK PG 0
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. J �9-6 cias5 "
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL VALIDAT ON
HOUSE SEWER CONNECTING TO DATE
PUBLIC SEWER am
B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FIN f 110 1
PITS AND/OR DRAINFIELD Q/y
Date HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 10ae
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 (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
is not intended or offered for sale (Section 7044,.Business z 3 3 3,2 A
and Professions Code). OWNER'S Permit .S
--
El 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE # 0 0 0 0 Q
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON TR CTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SE WER. �® I O o27,50
CONSTRUCTION LENDING AGENCY _
I herebyaffirm that there is a construction lendingage SIGNED THIS O-
Y OF �9
for the performance of the work for which this ermit S OWNER OR AGENT o - 27,505
,
issued (Sec. 3097, Civ. C.). OWNERSADDRESS I 0,29-85
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 a above-mentioned property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE