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Home My Public Portal About10420 KEY WEST ST_Sewer__ WORKERS'COMPENSATION DECLARATION E 808 ((2-80) CAPPLICATION FOR PERMIT {� CE 80LJ 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 - FOR FOR APPLICANT TO FILL IN CONNECTION DATA Certifie y i hereby furnished BUILDING /.�� _ STATION DEPTH Certified copy is filed with the county building inspec Ion ADDRESS JEAal�1 f department MANHOLE REFERENCE/ ��-�y� UP R LOCALITY wS G� LOWER ^ DateZ ��Apphcan� l NEAREST TYPE: OF CONNE CTI LENGTH FRO CERTIFICATE OF EXEMPTION OM RK S' cRoss sr v cuR6 P L M L TO P L COMPENSATION INSURANC P c No OWNER CO IMP NO JOB NO AIL (This section need not be completed if the work involved ADDRESS s TRUNK PERMIT NO ROAD PERMIT NO d by the permit is for one hundred dollars (.7Q100) or less.) AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE O CITY14�f_ T L NO V 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 so as to become subject to the Workers' Compensation Laws 0 BLOCK TRACT STATE ENCROACHMENT Date—'ApplicantPERMIT NO No of BLDGS / W NOTICE TO APPLICANT If, after making this Certificate of SIZE OF LOT DQ NOW ON LOT Exemption, USE OF p you should become subject to the Workers' gU1LDING2 CHARGES Z Compensation provisions of the Labor Code, you must'forth- with comply with such provisions or lthis permit shall be CONNECTION CHARGE FEE deemed revoked CONTR R REIMBURSEMENT FEE LICENSED CONTRACTOR'S DECLARATION ADDRESS I hereby affirm that I am licensed under provisions of Chapter DISTRICT No GROUP MAP D BY PROLE se CITYTEL NO BK PG 9 (commencing with Section 7000) of Division 3 of the Busi- nessand Professions Code, and my license is in full force and STATE:L CENSE Nos—�� G� CILASS effect NO DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING To FINAL p� VALIDATION License Number Lic Class PUBLIC SEWER DATE �� p SEPTIC TANK, SEEPAGE PIT OR COnte� PITS AND/OR DRAINFIELD FINAL HOUSE SEWER CONNECTING TO BY F1 PRIVATE DISPOSAL SYSTEM I am exempt fm 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, OR WELL,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 OWN ER'S Permit f License Law for the following reason (Section 7031 5, Busi- AUTHORIZATION TOTAL FEE 0;5 5 8 A ness and Professions Code) 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- 1 iT TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING O 10 O O 1 0 EJ 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 0�o r1 &O Q 7044, Business and Professions Code) OWNER oR OWNERS AG O O O 1 I�0 0 U CONSTRUCTION LENDING AGENCY ADDRESS . I hereby affirm that there is d construction lending agency for the performance of the work for which this permit is 07 2 9—,8 1 issued(Sec 3097,Civ C) - 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 bove-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur f Permltt Date