HomeMy Public PortalAbout10350 KEY WEST ST_Sewer__ WORkERS' COMPENSATION DECLARATION
I(herebyfaffirm that I have a certificate of consent to self }�
rf'.,,r, a certificate of Workers''Conlpensation Insurance, or 76A642D U
a-certified copy thereof (Sec 3800, Lob C , CE 806(REV 1/83) APPLICATION FOR PERMIT
Pollcy,No Company' „�
❑ Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL
['Certified copy is filed with rhe cou y building Ins ection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department '
Dote,&4pllcant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING p� STATION DEPTH
COMPENSATION INSURANCE. ADDRESS !/ Si
(This section need not be completed If the work Involved by the MANHOLE REFERENCE s'i:nE _L / UP
permit Is for one hundred dollars ($100)or less ) LOCALITY / WER
I certifythat in the performance Of the Work for which this NEAREST TYPE OF CONNECTION IENGTH FROM
p CROSS ST Y CURBP L M L TO P L
permit is Issued, I shall not employ any person in any manner
PC so as to become subject to the Workers'Compensation Lows OWNER 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 TEL NO 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 HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed /
reV
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 USEof
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
O�" CONNECTION CHARGE FEE
effect CONTRACTOR
License Number ' Lic ClassADDRESS qJ4S37 151REIMBURSEMENT FEE '
�j� DISTRICT NO GROUP MAP PR ESSED BY
Contractor Date d
CITY /�/ TEL NO ,[` /� BK PG V
❑ 1 am exempt under Sec of the L A Co LICENSE NO / 94 STAI CLASS ef — it r 0� Q ;
WORK F WFEE - Q
Plumbing Code and/or Sec of the NO DESCRIPTION OFINAL VALID ION v
HOUSE SEWER CONNECTING TO DATE21 �C
B & P Code for the following reason PUBLIC SEWERILU
_42 6SEPTIC TANK,SEEPAGE PIT OR O.
PITS AND/OR DRAINFIELD FINAL N
Date HOUSE SEWER CONNECTING TO BY Z
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 Contractors License EXTN,CESSPOOL,DRYWELL,MANHOLE
LOW 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 2 3 3 3,3 A
/ their sole compensation, will do the work and the structure
Is not Intended or offered for sale (Section 7044, Business # o 0.0 o 1 Q
and Professions Code) OWNERS Permit $
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE (� I o,. 27.50
licensed contractors to Construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO TRACTOR TO
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWERo o,o 2 7.5 Q U
CONSTRUCTION LENDING AGENCY �C� ,
I hereby affirm that there is a construction lending agency SIGNED THIS PAY OF a.2 9-8 5
for the performance of the work for which this permit Is OWNER OR
issued (Sec 3097, Civ C ) OWNERS AGENT i
Lender's Name Z ADDRESS
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
upoZthey/e-mentioned prrooperty for Inspection purposes
Signature of Permittee Date SIEE REVERSE FOR EXPLANATORY LANGUAGE