HomeMy Public PortalAbout10305 LA ROSA DR_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or ZeAe<RD LS
a certified m,.P�'�th�ertt��eoyyf��(Sec. 3800, Lab .,- / CE BDB,REY.6/811gpp�ICATION FOR PERMIT
Policy No.15_Z1: L6ompany �f�iOs
❑ Cee ified copy is hereby furnished. SEWER - SEWAGE DISPOSAL .
L�'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
COMPENSATION INSURANCE ADOREss ,,5 STATION DEPTH
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
LOCALITY Xx LOWER
permit is for one hundred dollars ($100)Of Hess.) NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance Of the work for which this cRoss ST. Y. CURB P.L. MA.TO P.L. >_
permit is issued, I shall not employ any person in any manner L r d
so as IO become subject t0 the Workers'Compensation Lows. OWNER /,� �G— CO.IMP.NO. JOB NO, O
MAR �i ,fi '/ f V
OIe Appl iconf ADDRESS ®B2 � S`/6C�r�l TRUNK PERMIT NO. ROAD PERMIT NO. Ce
NOTICE TO APPLICANT: If, after makingthis Certificate Of aC q AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE 0
CITY a� TEL.NO. ,_" 6�✓0'
Exemption, you should become subject to the Workers' LEGAL _ W
Compensation provisions of the Lobar code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING Il
comply with such provisions or this permit shall be deemed _J p W
revoked. BLOCK TRACT /�p 1!V STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS, PERMIT No,
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF X S
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect CONIRACTOR CONNECTION CHARGE FEE
License Nu�mybber, G/ 90'9/ 1/'Lic.Class oe5// ADDRESS REIMBURSEMENT FEE
COntroc�/yAr111/1C_ Date 44�' J!:.j.
CITY TEL.NO. DISTRICT NO. GROUP MAP OCESSED kY
BK PG
STATE LIC.
am exempt under Sec. of the L.A.Co. tICENSE ND. �6 CLASS f `-
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK HE FINAL
HOUSE SEWER CONNECTING TO / i DATE / —�� VALIDATION
B. 8 P. Code for the following reason PUBLIC SEWER (o Cl
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY _�- ••�J ..
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ►
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
hereby affirm that am exempt from the Contractor OVERFLOW SEEPAGE PIT,GRAINFIELD
5 License EXIN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE x.5.0 9.9 A
fessions Code): SEWER OR DISPOSAL SYSTEM
0 0 0 0 0.
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the.work and the structure - `[Fo - 2 7,50
is not intended or offered for sale (Section 7044, Business J and Professions Code). OWNER'S Permito 75 0
El1,as Owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors 10 construct the protect (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 0 Q,0.9—8 3
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency. SIGNED THIS DAY OF 191rs
for the performance of the work for which this permit is OWNER OR
p p
issued ($e<. 3097, Civ. C.). OWNERS AGENT
ADDRESS i
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
/aabbove-mentioned property fo sspectiioon/puurpoosses.
Signature of minee / Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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