HomeMy Public PortalAbout10380 KEY WEST ST_Sewer__ WORKERS'COMPENSATION DECLARATION CE 808 (D2-80) 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. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
S� d
71-,r4 FOR APPLICANT TO FILL IN CONNECTION DATA
CArtlficopy is hereby furnished. ,/ /.�
' BUILDING w _y STATION it� � DEPTH / ��wr
Certified co is filed with the count building ADDRESS �J a �/ Kti
departmen Py y g inspe Ion MANHOLE REFERENCE:�i-�Y �lyl U
Z� — LOCALITY W7 i.�✓ ,;2 OWER
D e Applica NEAREST TYPE OF CONNEC N LENGTH FRO
CERTIFICATE OF EXEMPTIO OM) O RS' cRoss ST. Y. CURB P, M.L. TO P.L.
COMPENSATION INSURAtKE P.C. No. ,r
OWNER CO. IMP. NO. JOB NO. }
(This Section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. tZ
by the permit is for one hundred dollars ($100) or less.) � r / O
WAI
w j / AFFIDAVIT VER EASEMENT RECORD. INSTR. NO. DATE
CITY TEL. NO. G 7
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 F-
so as to become subject to the Workers' Compensation Laws. U
BLOCK TRACT STATE ENCROACHMENT LU
Date Applicant - NOW
OF BLDGS. PERMIT NO. 0L
NOTICE TO APPLICANT: If, after making this Certificate of slzE of Lor rvow ory Lor
Exemption, you should become subject to the Workers' USE OF
Compensation provisions of the Labor Code, you must forth-
BUILDINGSy� CHARGES
with comply with such provisions or this permit shall be corvTR CONNECTION CHARGE FEE
deemed revoked.
REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter DISTRICT o. GROUP BK MAP PG PROCESSED BY
9 (commencing with Section 7000) of Division 3 of the Busi- STAT LIC.
CITY TEL. NO.
ness and Professions Code, and my license is in full force and LICENSE rvo.����G % CLASS �
effect.
_ NO. DESCRIPTION OF WORK FEE _
� HOUSE SEWER CONNECTING TO / FINAL VALIDATION
License C iSb Lic.Qass I, PUBLIC SEWER / DATE
SEPTIC TANK, SEEPAGE PIT OR
/GG JF�7y
to PITS AND/OR GRAINFIELD
FINAL I
HOUSE SEWER CONNECTING TO BYt-
❑ , PRIVATE DISPOSAL SYSTEM C"-
I a exempt ro the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER l
acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD
mess and Professions Code). 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 f
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- 20 5 5.3 A
O TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING '
1, as owner of the property, will do the work and the TO THE PUBLIC SEWER.
#/O O O O 1.0
structure is not intended or offered for sale (Section SIGNED THIS DAY OF 1
7044, Business and Professions Code). OWNER OR
2 0 0 0 0
OWNERS AGE
CONSTRUCTION LENDING AGENCY ADDRESS o 0 0
I hereby affirm that there is a construction lending agency 1 8.005
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.). 0 7 2 9'-81
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 property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o ermittee Date