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HomeMy Public PortalAbout10405 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,La COUNTY OF LO&ANGELES BUILDING AND SAFETY Yollc No r Company- -1/�—��� N r�G FOR APPLICANT TO FILL IN CONNECTION DATA Cer i e copy is hereby furnished / BUILDING STATION���� DEPTH /,. ❑ Certified copy 15 filed wi=thety bulldmg 1 5 tion ADDRESS �, l!' PPE! p �L'�S.79 de ailment MANHOLE REFERENCE FJ LOCALITY LOWER Dyfe ���� Appllc NEAREST TYPE OF CONNECT LENGTH FR OM +� CERTIFICATE OF EXEMPTIO ROMIOERS' cRoss ST Y CURB P L M L To P L COMPENSATION INSURAN EP c No OWNER I CO IMP NO JOB NO / MAIL / (This section need not be completed if the work involved ADDRESSTRUNK PERMIT NO ROAD PERMIT NO a by the permit is for one hundred dollars ($100) or less.) p � r/) AFFIDAVIT •WAIVER EASEMENT RECORD INSTR NO DATE O CITY /6�TEL NO I certify that in the performance of the work for which this LEGAL permit is issued,' I shall not employ an person in any manner DESCRIPTION LOT No O p P Y Y P HWY OR ST WIDENING so as to become subject to the Workers' Compensation Laws ��f /+� 0 BLOCK TRACT ��S ! / STATE ENCROACHMENT PERMIT NO V Date Applicant i No of BLOGS / W NOTICE TO APPLICANT If, after making this Certificate of sizE of LOT �S Now ON LOT U) Exemption, you should become subject to the Workers' USE OF Compensation BUILDINGS - CHARGES Z p provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall beCONNECTION CHARGE FEE , deemed revoked CONTRACTOR REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I am licensed under provisions of Chapter ..STRICT NO GROUP BK MAP PG PROC SSE.8 Y CITY — STA 9 (commencing with Section 7000) of Division 3 of the Busi- , ,r TEL rvo ness and Professions Code, and my license is in full force and LICENSE NOTE (� �� y CLASS effect / - NO DESCRIPTION CT WORK FEE p� HOUSE SEWER CONNECTING TO FINAL +I� .�y ) VALIDATION License N er Lie Class PUBLIC SEWER DATE JJ �©J r �J ,/f,� SEPTIC TANK,SEEPAGE PIT OR C ate C C/ PITS FND/OR .RAINFIELD ✓ FINAL HOUSE SEWER CONNECTING TO BY ❑ PRIVATE DISPOSAL SYSTEM v I am exemp fr 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 ness and Professions Code) I HAVE z�0 5 S5 A AT THIS DATE A CONTRACT WITH THE HEREIN NAM EO CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING 1, as owner of the property, will do the work and the TO THE PUBLIC SEWER e # DID O D 1, 0 structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19 7044, Business and Professions Code) OWNER OR 2 Di° 1 8,00 OWNERS AGENT CONSTRUCTION LENDING AGENCY ADO.E59 O O 1 Q'0 0 I hereby affirm that there is a construction,lending agency O for the performance of the work for which this permit is issued (Sec 3097,Civ C) 07.29" 8 1 Lender's Name Lender's Add-ess 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 pur uses SEE,REVERSE FOR EXPLANATORY LANGUAGE Slgnatur Perm itte Date