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Home My Public Portal About10400 KEY WEST ST_Sewer__ WORTCERS'COMPENSATION DECLARATION D CE 808 (2-80) APPLICATION FOR PERMIT CE 808 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,Labe COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy / pp Company ❑ Ceft4�ijed/c2py�is ereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING `w STATIODEPTH Certified copy is filed with the county building I pe Ion ADDRESS V/7LK✓/ �! (Y PPE department LOCALITY MANHOLE REFERENCE0�/')` 72 LOWER DateLApphcan NEAREST _ TYPE OF CONNEC`! w` LENGTH FROMiy CROSS ST Y CURB P L M L TO P L �¢_J / CLRTIFICATE OF EXEMPTIO) ROM W RS' COMPENSATION INSURANC P C NO 7 OWNER CO IMP NO JOB NO MAIL ' (This section need not be completed if the Qwork involved ADDRESS S_ TRUNK PERMIT NO ROAD PERMIT NO d by the permit is for one hundred dollars ($100) or less.) AFFIDAVIT WAVER EASEMENT RECORD•INSTR NO DATE O CITY TEL NO L/ U 1 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 -.00,111 HWY OR ST WIDENING Cr so as to become subject to the Workers' Compensation Laws 7 H BLOCK TRACT 7�/ STATE ENCROACHMENT U PERMIT NO Date Applicant No OF BLDG W NOTICE TO APPLICANT If, after making this Certificate of sizE of LOT B© NOw ON LOT W Exemption, you should become subject to the Workers' USE OF Compensation provisions of the Labor Code, BUILDING CHARGES Z p p you must forth- with comply with such CONNECTION CHARGE FEE p y provisions or this permit shall be CONT deemed revoked REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I am licensed under provisions of Chapter CITU TEL NO DISTRICT NO GROUP BK MAP P PROCESSED BY STATI 9 (commencing with Section 7000) of Division 3 of the Busi- / Q / ness and Professions Code, and my license is in full force and L CENSE NCO[Z//; 5t&r 0 CLASS effect NO DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO FINAL 9_?, !a-9� VALIDATION Lrcense N mber �r Li Class— PUBLIC SEWER DATE �Jx �_C GJ / SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR CONNECTING FINAL ate �fJ HOUSE SEWER CONN EGTING TO BY ❑ PRIVATE DISPOSAL SYSTEM I am exe pt rom the licensing requirements as I am a 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 iness and Professions Code) EXTN ,CESSPOOL,DRV WELL, MANHOLE ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM L.c 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 2 0 5 5 4 A ness and Professions Code) I HAVE AT THIS DATE A CONTRACT WITH THE NEREI NAMED CON-TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING # � 1 I, as owner of the property, will do the work and the TO THE PUBLIC SEWER O•OIOp 0 structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19 p 7044, Business and Professions Code) OWNER OR 2 ° °,1 O 0 0 OWNERS AG CONSTRUCTION LENDING AGENCY ADDRESS ;0,0 ° 1 & 0 0 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 0729—8 1 issued(Sec 3097,Civ C) 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 0rdmances and State laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned proper�fnspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o ermitte Date