HomeMy Public PortalAbout10360 KEY WEST ST_Sewer__ r
VVORKERS'COMPENSATION DECLARATION CE 8082 (_80) APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
Insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C A COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy y Company
/L� �c� FOR APPLICANT TO FILL IN CONNECTION DATA
❑ Certified copy is hereby furnished
BUILDING STATION DEPTH
1Z Certified co is filed with the count building inspection ADDRESS U
PY Y g P ���// y, UPPER
de artment REFERENC / t
LOCALITY MANHOLE
J LOWER
Date Applican G�� NEAREST TYPE OF CONNE LENGTH FROM y(��
CERTIFICATE OF EXEMPTION FRO RKERS' CROSS ST Y CURB P L.' M L TO P L
COMPENSATION INSURANCE 7.
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OWNER CO IMP NO JOB NO }
MAIL IZ
(This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO ROAD PERMIT NO. O
by the permit is for one hundred dollars ($100) or less.)
�� AFFIDAVIT WAIVER EASEMENT RECORD INSTR. NO 'DATE y
CITY TEL NO
I certify that in the performance of the work for which this LEGAL
permit is Issued, I shall not employ any person in any manner DESCRIPTION LOT No �... HWY. OR ST WIDENING
so as to become subject to the Workers' Compensation Laws U
BLOCK TRACT STATE ENCROACHMENT w
Date Applicant NO. OF BLDGS PERMIT NO d.
SIZE OF LOT �s'Q�J NOW ON LOT to
NOTICE TO APPLICANT If, after making this Certificate of Z
Exemption, you should become subject to the Workers' USE OF CHARGES —
Compensation provisions of the Labor Code, you must forth- BUILDINGS
with comply with such provisions or this permit shall beCONNECTION CHARGE FEE
deemed revoked corvrRAc
REIMBURSEMENT FEE ,
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter K PG DISTRICT NO GROUP MAP PROCESSED BY
L
9 (commencing with Section 7000) of Division 3 of the Busi- clTr TEL No. B
ness and Professions Code, and my license is in full force and STATE ` LIC
effect J/�//�� f
LICENSE No. CLASS /� r
-
NO DESCRIPTION OF WORK FEE
c� HOUSE SEWER CONNECTING TO FINAL VALIDATION
Licens �ber'� Lic Class-9
,) �/ PUBLIC SEWER DATE
<� SEPTIC TANK,SEEPAGE PIT OR
n r r Date PITS AND/OR DRAINFIELD
HOUSE SEWER CONNECTING TO
BY AL
a PRIVATE DISPOSAL SYSTEM
I am ex t from the licensing requirements as I am a d
CONNECT ADDITIONAL BLDG.OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD
mess and Professions Lode). EXTN.,CESSPOOL, DRYWELL, MANHOLE
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic.or Reg.No Date
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNERS Permit i
License Law for the following reason (Section 7031 5, Busi- AUTHORIZATION TOTAL FEE
ness and Professions Code) I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- 0 5 5 1 A
El1,
TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING •
I, as owner of the property, will do ttie work and the TO THE PUBLIC SEWER. # o 0'0'0 1 0
structure is not Intended or offered for sale (Section SIGNED THIS DAY OF 19
7044, Business and Professions Code) OWNER OR2 0 0,1
OWNERS AGE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency ADDRESS 2 0 0 1 8,0 0 2:
for the performance of the work for which this permit is
Issued (Sec 3097,Civ C). 0.7 2 9 8 1
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 the above-mentioned proper y for ectlon purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ermittee Date