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Home My Public Portal About10415 KEY WEST ST_Sewer__ WOt'ZKERS'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 'fl a certified copy thereof(Sec 3800,La COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company p�s hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA/ BUILDING STATION =� DEPTH Certified copy is filed with the county building I ecrion ADDRESS D PE �d/epartmenet / LOCALITY MANHOLE REFERENCE �D J /I� LOWER Dater Zfl G Applica NEAREST TYPE OF CONNECTIO I `1 LENGTH FROM CERTIFICATE OF EXEMPTION OM W S' CROSS ST Y CURB L M L To P L COMPENSATION INSURANCE J c No �J OWNER CO IMP NO JOB NO MAIL (This section need not be completed If thework involved ADDRESS TRUNK PERMIT NO ROAD PERMIT NO O by the perm[t 1s for one hundred dollars ($lOO) OI less.) AFFIDAVIT I WAVER EASEMENT RECORD INSTR NO DATE U - CITY �'� TEL NO � �"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 Af0 HWY OR ST WIDENING so as to become subject to the Workers' Compensation Laws �7�/ U BLOCK TRACT STATE ENCROACHMENT - W Date Applicant 4 NO OF BLDGS PERMIT NO d SIZE OF LOT E�,� (J NOW ON LOT NOTICE TO APPLICANT If, after making this Certificate of Z Exemption, you should become subject to the Workers' USE OFCHARGES - Compensation provisions of the Labor Code, you must forth- BUILDING S with comply with such provisions or this permit shall beCONTRACTOR. CONNECTION CHARGE FEE _ deemed revoked REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS CITY TEL NO DISTRICT NO GROUP BK PR OC SSE. BY I hereby affirm that I am licensed under provisions of Chapter BK PG 9 (commencing with Section 7000) of Division 3 of the BusiSTATE- ness and Professions Code, and my license is in full force and LICENSE No clLAss �� 3 effect NO DESCRIPTION OF WORK FEE ,+� p( E SEWER CONNECTING TO FINAL n�/ .�y� VALIDATION License Number Lic Class HOUS / PUBLIC SEWER DATE TC/JJy\\ FfItL/ SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD C ate L FINAL HOUSE SEWER CONNECTING TO BY F1PRIVATE DISPOSAL SYSTEM �u I am exefrm m the licensing requirements as I am a CONNECT ADDITIONAL BLDG OR q licensed architect or a registered professional engineer WORK TO HOUSE SEWER 1 acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD iness 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 OWNER'SPermit L FEE s License Law for the following reason (Section 7031 5, Busi- AUTHORIZATION TOTAz 0 5 57 A ness and Professions Code) I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- ❑ TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING # 0'0,0.0 1 0 1, as owner of the property, will do tlie work and the TO THE PUBLIC SEWER . structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19 2 o;0'1 8.00 7044, Business and Professions Code) OWNER OR OWNERS AGENT CONSTRUCTION LENDING AGENCY ';° °,1 &0 0 0 ADDRESS I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 0,7,,2,9'-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 ordinances and State laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned property-for in n purpo s SEE REVERSE FOR EXPLANATORY LANGUAGE Signat f Permi a Date