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Home My Public Portal About10310 LA ROSA DR_Sewer__ WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self DISI insure, or a certificate of Workers' Compensation Insurance, or 7eAea4D a certified co y thereof (Sec. 3800, Lob C.) CE BDB(REV,6/8 1) APPLICATION FOR PERMIT Policy NCompany �� /Le! ®s� ❑ 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. Dote Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADORfSS STATION DEPTH (This section need not be completed if the work involved by the MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or less.) LOCALITY C LOWER I AR EST TYPE OF CONNECTION tfNGTH FROM I certify that in the performance of the work for which this CROSSST. f//j Y. CURB P.I. MA TO PA. Y permit is issued, I shall not employ any person in any manner 0 so as to become subject to the Workers'Compensation Laws. eC.NO. P OWNER �j iffy%��L CO.IMP.NO. JOB NO. u MAIL Date Applicant ADDRESS �j / TRUNK PERMIT NO. ROAD PERMIT NO. AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO, DATE O NOTICE TO APPLICANT: If, after making this Certificate of CITY TELNO. U 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 d comply with such provisions or this permit shall be deemed2 F Z revoked. BLOCK TRACT C, �� </ STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF 81 ., PfRMn NO. SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 1S` 9 (commencing with Section 7000) Of Division 3 of the Busi- BUILDINGS CHARGES Hess and Professions Code, and my license is in full force and effect. 7 QQ'' J�j� /` CONTRACTOR CONNECTION CHARGE FEE License N•uymbb.F— 5y_4 1/ Lic.Class 1✓/ ADDRESS �J' - rDATE RSEMENT FEE ContraCX wr2Z /�.% Date CT NO. GROUP MAP PR CESSED BY CITY TEL.NO. BK WG ❑ I am exempt under Sec. of the L.A.Co. LICENSE �j/ UC. �^ P LICENSE NO. ��OYt �� CLASS /�, C�ov ��NO. DESCRIPTION OFWORK FEE Plumbing Codeand/or Sec. of the /rHouSE SEWER coNNEcnNG To � '( s/�' VALIDATION B. 8 P. Code for the following reason PUBUC SEWER •�SEPTIC TANK,SEEPAGE LPITD OR PITS AND70R DRAINFIELDDate HOUSf SEWER CONNECTING i0 y— PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR - OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER , S O 4 A 1 hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDE%i N.,CESSPOOL,DRYWELI,MANHOLE ' Law for the following reason (Secton 7031.5, BVisness and,Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Cade): - SEWER OR DISPOSAL SYSTEM ❑ I, as owner of the property,or my employees with wages as I2 u c 217.5 Q their sole compensation, will do the work and the structure o'R a 2 7.5 0 csi is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ f ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE - '�•9 O 8�3 licensed contractors to Construct the project (Section 7044; 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 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 for the performance of the work for which this permit is OWNER 01 issued (Sec. 3097, Ci, C.). OWNERS ADEN ADDRESS Lender's Name Lender's Address ' I certify that I have read this application and state that the ' above informaiion 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 prper _for inspe tion purposes. , Date Signalu f Permit a SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 7eAU2D a certified co y,l /greof (Sec. 3800, Lab C.,) ®ees IREv.a/sry APPLICATION FOR PERMIT Policy No: % Company s ❑ 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' eunD1NG } COMPENSATION INSURANCE 9 STATION DEPTH IL (This section need not be completed if the work involved by theLOCALITY MANHOLE REFERENCE SRR 0 permit is for one hundred dollars ($100)or less.) NEAREST TYPE OF CONNECTION LENGTH FROM j certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L.TO RA.. permit is issued, I shall not employ any person in any manner LL so as to become subject to the Workers'Compensation Laws. OWNER CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO, Data Applicant ADDRESS OAC NOTICE TO APPLICANT: If, after making this Certificate Of CITY TEL NO AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO. DATE O Exemption, you should become subject to the Workers' d Compensation provisions of the Labor code, you must forthwith DEscmLEGAL LOT No. P P Y HWY.QRST.WIDENING W comply with such provisions or this permit shall be deemed H revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION ND.OF SLOGS. PERMIT NO. SIZE OF LOT NOW ON LOT I hereby affirm that I Se licensed under provisions of Chapter USEOf 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES new and Professions Code, and my license is in full force and effect. CONTRACTOR NNECTION CHARGE FEE License Number - / Lic.Claes ` ADDRESS MBURSEMENT FEE Contractor Date ' STRICT NO. GROUP MAP PROCESSED BY CITY TEL,NO BK PG ❑ I am exempt under Sec. of the L.A.Co. STATE Dc Y P UCENSE NO. CLASS44DATE Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEEHOUSE SEWER CONNECTING TO VALIDATION B. 8 P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR Date PITS AND/OR DRAINFIELD AL HOUSE SEWER CONNECTING TO PRIVATE D15MS L SYSTEM Signature CONNECT ADDITIONAL BLDG.OR J C Tt OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ► - OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL.DRYWELL,MANHOLE - e e 9 r Law for the following reason (Sefton 7031.5, Buisness and Pro- ALTER.REPAIR OR ABANDON HOUSE feaaions Code): SEWER OR DISPOSAL SYSTEM ,F . .• i 7 ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure • • • ~' `1 is not intended or offered for sale (Section 7044, Business f and Professions Code). OWNER'S Permit 10/fw-- r r,7- 1, ,,7_1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 1' ) licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 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 19_ for the performance of the work for which this permit is OWNER OR issued (Sec. 3077, Civ. C.). OWNERS AGENT ADDRESS Lender's Nome 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 inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE