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HomeMy Public PortalAbout10425 KEY WEST ST_Sewer__ i –ff 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(See 3800, Lav__91� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company—�c & ��yV FOR APPLICANT TO FILL IN CONNECTION DATA e tl ie c y ereby furnished BUILDING STATION DEPTH / Certified copy is filed with the county building inspection ADDRESS N/➢ PE dartment C / MANHOLE REFERENCE / 0 �i"' [LOCALITY LOWER 4 Datee aZ� Applicant - NEAREST TYPE OF CONNECTI LENGTH FRO CERTIFICATE OF EXEMPTION F M W RKE S' CROSS sr / Y CURB P L ' M L ro P L COMPENSATION INS RANCE J c No OWNER CO IMP NO JOB NO MAIL (This section need not be completed if the work involved ADDRESS �� J G( �(/�/ TRUNK PERMIT NO ROAD PERMIT NO d by the permit is for one hundred dollars ($100) or less.) I /. AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE O CITY NO C!A U 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 cc so as to become subject to the Workers' Compensation Laws 7�7 0 BLOCK TRACT STATE ENCROACHMENT U PERMIT NO Date Applicant No of BLD GS �/ LU NOTICE TO APPLICANT If, after making this Certificate of SIZE OF LOT soa NOW ON LOT (OF CL Exemption, j BUILDING DINGS p you should become subject to the Workers' BUILDINGS CHARGES G Compensation provisions of the Labor Code, you must forth- © G ,with comply with such provisions or this permit shall be CONTRACTOR CONNECTION CHARGE FEE� � ��/ deemed revoked _ REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I am licensed under provisions of Chapter DISTRICT No GROUP MAP PRO sgED BY 9 (commencing with Section 7000) of Division 3 of the Busi- CITY TEL NO a ness and Professions Code, and my license is In full force and LICENSE No Z�S 66 CILASS v` V ! O effect NO DESCRIPTION OF WORK FEE p�� ///J�� /// HOUSE SEWER CONNECTING TO FINAL _ VALIDATION License Nuri J L1C CI ss 1 PUBLIC SEWER Ir DATE SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL Copt C Y/ G_C� HOUSE SEWER CONNECTING TO BY El PRIVATE DISPOSAL SYSTEM �1 ' I am exempt om a licensing requirements as I am a v 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) EXTN ,CESSPOOL,DRYWELL, MANHOLE ALTER, REPAIR OR ABANDON HOUSE ' SEWER OR DISPOSAL SYSTEM Lie 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) 9 0 5 5 9 A 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- , 'TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I, as owner of the property, will do the work and the TO THE PUBLIC SEWER # O O D'O 1 0 structure Is not intended or offered for sale, (Section SIGNED THIS DAY OF 19 7044, Business and Professions Code) OWNER OR 2 0`0 1 a 0 0 OWNERS AGENT CONSTRUCTION LENDING AGENCY ADDRESS 0 0 1 0 0 I hereby affirm that there Is a construction lending agency ; h , 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 ove-mentioned prop,erty r inspection purposes / SEE REVERSE FOR EXPLANATORY LANGUAGE Signature Permit/ ate `orf/