HomeMy Public PortalAbout10300 LA ROSA DR_Sewer__ i
/ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self ILII
insure, or a certificate of Workers'Compensation Insurance, or 7EAe42D
a certified thereof (Sec. 3800, L , CE 806 LV.B/BI) APPLICATION FOR PERMIT -
Policy Na�� 97/Company (6s
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING / STATION DEPTH
COMPENSATION INSURANCE ADDRESS 6< {
(This section need not be completed if the work involved By the UPPER
LOCALITY CC >� MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100)or less.)
TYPE OF CONNECTION
I certify that in the performance of the work for which this NEAREST .L.
permitt i LENGTH FROM
s issued, CROSS ST. Y. CURB P.L. M.L.TO P
shall not employ any person in any manner IL
PX NO.
so as to become subject to the Workers' Compensation Laws. OWNER `MI6«��� CO.IMP.NO. JOB NO. OMAIL '
V
Date-Applicant ADDRESS -� TRUNK PERMIT NO. ROAD PERMIT NO. C
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO, DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY r/ TEL.NO, 1 V
Exemption, you should become subject to the Workers' LEGAL w
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST,WIDENING 1
comply with such provisions or this permit shall be deemed w
revoked. BLOCK TRACT STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION NO. ON L
OF BLDGS. PERMIT NO.
hereby affirm that SIZE OF LOT NOW am licensed under provisions of Chapter USE of OT
l
CHA
9 (commencing with Section 7000) of Diviston 3 of the BUS- SURDINGS RGES
ness and Professions Code, and my license is in full force and
effect. / CONTRACTOR CONNECTION CHARGE FEE
License Number�-rK':7f) C LIC.Class 1:03 / ADDRESS REIMBURSEMENT FEE
Contract .��..ar/F/� Date � :0 CITY TEL.NO, DISTRICT NO. GROUP MAP P OCESSED BY
BK FG
+1'� F
Llam exempt under Sec STATE LIC.
�- of the L.A.Co. LICENSE NO. Cr
DESCRIPTION OF WORK FEE, 7 ��a
Plumbing Code and/or Sec. ofthe NODESCRIFINAL '
' HOUSE-SEWER CONNECTING TO ,/ DATE ®' VALIDATION
B. 8 P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY -
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAPIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOLGE.DRYWELL,MANHOLE
Law for the following reason (Sectan 7031.$, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM c 5 0 83 A
El 1, as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure # 0 0 ....1 0
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit g / 10 - 27,50
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION FTOTAL FEE - q
licensed contro Clors to construct.the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRAC R TO Oto O 2 I,S 0 U
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY - - Poo. o9.0 9'—8 3
1 hereby affirm that there is a construction lending agency - SIGNED THIS DAY OF
for the performance of the work for which this permit is OWNER OR .�`
issued (Sec. 3097, Civ. C.). OWNERS AGENT
ADDRESS
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 outhorize representatives of this County to enter
Upon the above-mentioned pro for inspection p rposes.
Signa of Perm' a Date SEE REVERSE FOR EXPLANATORY LANGUAGE -