HomeMy Public PortalAbout10410 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 I I 'fl
a certified copy thereof(Sec 3800, bs—C r / COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No pCompan,�r'��-e 2
Lr� l K FOR APPLICANT TO FILL IN CONNECTION DATA
Certi ie o y is hereby furnished /}
BUILDING � STATION �"� / DEPTH y
�]I ADDRESS � vPP
'ST/ ' Certified copy Is filed with the county building mspec n �X �r
department LOCALITY MANHOLE REFE641
RENCE r ✓ LOWER
DatP� f--'/Applicant NEAREST TYPE OF CONNEC N LENGTHFROM
CERTIFICATE OF EXEMPTION 1`13114M WO S' CROSS ST Y CURB P M L To P L
COMPENSATION INSURANCE P c NO 'J
OWNMAILER CO IMP NO JOB NO /
(This Section need not be completed if the work involved ADDRESS TRUNK PERMIT NO ROAD PERMIT NO d
by the permit is for one hundred dollars ($100) or less.) /j �� gFFIDAVIT WAVER EASEMENT RECORD INSTR NO DATE O
CITY EL NO CSJr�
I certify that in the performance of the work for which this LEGAL fr
permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO HWY OR ST WIDENING 0
so as to become subject to the Workers' Compensation Laws
STATE ENCROACHMENT
BLOCK TRACT
PERMIT NO W
Date ApplicantNO OF BLDGS n
NOTICE TO APPLICANT If, after making this Certificate of SIZE OF LOT S OC7 NO ON LOT Z
Exemption, you should become subject to the Workers' USE OF
BUILDINGS CHARGES
Compensation provisions of the Labor Code, you must forth-
with comply with such CONNECTION CHARGE FEE
p y provisions or this permit shall be CONTRACT
deemed revoked REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO GROUP MAP PROCESSED BY
eK J
9 (commencing with Section 7000) of Division
TEL NO ision 3 of the Busi- PG -
ness and Professions Code, and my license is in full force and STATE L IC LICENSE NO cLAss S,o� —J
effect �Y�
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO FINAL �j ' �✓ �J� VALIDATION
License N tuber LIC Class—"6 —/ PUBLIC SEWER DATE UxU[
SEPTIC TANK,SEEPAGE PIT OR A
tra ate �� S� PITS AND/OR
DRAINFIELD FINAL
HOUSE SEWER CONNECTING TO G
❑ PRIVATE DISPOSAL SYSTEM BY
I am exemp f m 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
mess and Professions Code) E%TN ,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 S
License Law for the following reason (Section 7031 5, Busi- AUTHORIZATION TOTAL FEE
ness and Professions Code) :2 05 5.,8 A
1 HAVE T THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR
TO CONNECT THE ABOVE DESCRIBED E%ISTING DWELLILI NG
EDI, as owner of the property, will do the work and the TO THE PUBLIC SEWER #io o)o 0 1.0
structureis not intended or offered for sale (Section SIGNED THIS DAY OF
no
7044, Business and Professions Code) OWNER OR 21.-;- 1 Q 0 0
OWNERS AG
CONSTRUCTION LENDING AGENCY ADORES. .o o to,10 0 czi
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec 3097,Civ C) 0,7.29-811
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 propert fo inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of ittee Date