HomeMy Public PortalAbout10315 LA ROSA DR_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I hove a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D '
a certified copy thereof (Sec. 3800, Lo�C.) CE FOR(REV.B/BI( APPLICATION FOR PERMIT
'Policy No �3 � /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' 90'EDING -� / STATION - - DEPTH
COMPENSATION INSURANCE ADDRESS O� �s 4 p,
(This section need not be completed if the work involved by the LOCALITY ,1 / MANHOLE REFERENCE UPPER
Permit is for one hundred dollars ($100)or less.) C- LOWER
I certify that in the performance of the work-for which this CROSSSSTAr- � TYPE OF CONNECTION M.L.TO FROM
Y. CURB P.L. M.L.TO P.I. ,}
permit is issued, shall not employ any person in any manner v.C.NO. n'
s0 as t0 become subject IO the Workers Compensation Laws. OWNER /� v�%��MAIL �! CO.IMP NO. JOB NO. o
ADDRESS Q ( � TRUNK PERMIT NO, ROAD PERMIT NO. Ix
Date Applicant _
NOTICE TO APPLICANT: If, after makingthis Certificate O{ AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE O
CITY (� TEL NO. Gs'f �fry
Exemption, you should become subject to the Workers' U
Compensation provisions of the Labor code, you must forthwith LEGAL w
P P Y DESCRIPTION LOT NO. HWY.OR Si.WIDENING 1
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT v t! STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION NO.OF BLDOS, PERMIT NO.SIZE OF LOT NOW ON LOT J
hereby affirm that Se licensed under provisions of Chapter USE OF f
9 (commencing with ode, a d my of Division 3 of the Buxi-
and
BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. / CONTRACTOR CONNECTION CHARGE FEE
License NU mbeT�L lc. Class / ADDRESS REIMBURSEMENT FEE
DISTRICT NO. GROUP MAP PR CESSED BY
COntracfio5�-C, y�ai Date p ! 6 7_ CITY TEL.No. �� / BK PG
❑ am exempt under Sec. of the L.A.Co.• LICENSE NO. 2_4,5-9.,- CLASS -
Plumbing Code and/or Sec. of the No. DESCRIPTION OF W RK FEE FINAL
HOUSE SEWER CONNECTING TO ! DATE //_' ALIDATION
B. &P. Code for the following reason PUBLIC SEWER ((p
SEPTIC TANK,SEEPAGE PIT OR
PITS Ai DRAICONNECTING
FINAL
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
hereby affirm that am exempt from the Contractor's license EXTN.,CESSPOOL DRYWELL.MANHOLE
Law for the fOliOWing reason (Secton 701 Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 5.1 0,0 A
fessions Code): SEWER OR DISPOSAL SYSTEM '
El1, e I,as owner of the property,or my employees with wages as ,o e 1 0I
their sole compensation, will do the work and the structure 2'^ - 27. 5 0
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit - $ qrn
Ll 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEEZZ
`0 0 02 7,5 0 v
licensed contractors to construct the project (Section 7044, AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ONi ACT i0 0909-83
BU$Ine$$and PFO{eSSIOnS 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 6
AG
issued (Sec. 3097, Civ. C.). OWNERS ENT
ADDRESS
Lender's Name '
Lender's Address -
I Certify that I have read this application and state that the -s
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 avove-mentioned�r perty_for inspecti n purposes. ,
Signature errea Date SEE REVERSE FOR EXPLANATORY LANGUAGE