HomeMy Public PortalAbout10320 LA ROSA DR_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self f l LI IS
insure, or a certificate of Workers'Compensation Insurance, or ReA°aso
a certified 5 thereof (Sec. y0 La - Z �>3D�tREv.B,Bt, APPLICATION FOR PERMIT
Policy No. �Compony
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL _
ElCertified 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 /A '
COMPENSATION INSURANCE ADeRess ":g v STATION DEPTH
(This section need not be completed if the work involved by the LOCALITMANHOLE REFERENCE UPPER
permit is for one hundred dollars'($100)or less.) NE-Es, ZtF� LOWER
I certifythat in the performance of the work for which this NEAREBS TYPE OF CONNECTION LENGTH MLJOELE
P CROSS Si. Y. CURB P.L. M.L. . . Y
permit is issued, I shall not employ any person in any manner J P,C.NO. Q
so as t0 become subject to the Workers Compensation Laws. OWNER / CO.IMP.NO. JOB NO. u
MAIL /a TRUNK PERMIT NO. ROAD PERMIT NO,
Date Applicant ADDRESS Q �J r/� �✓
AFFIDAVIT WAIVER EASEMENT RECORD,INSTR. O
NOTICE TO APPLICANTIf,•after Making this Certificate Of CITY Ij TELNO.
U
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT No. / W
complywith such provisions or this HWY.OR ST.WIDENING d
p permit shall be deemed �� a
revoked. BLOCK TRACT STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION NG.OF BLOCS, PERMIT NO.
SIZE OF LOT NOW ON LOT ,
I hereby affirm that I am licensed under provisions of Chapter usE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUImINGsj U �� CHARGES.
Ness and Profession$ Code, and my license is in full force and
effect. AA�� �'' CONTRACTOR CONNECTION CHARGE FEE
License NumbelC -l�jJ�-/ Lip Class /Z51 �? ADDRESS REIMBURSEMENT FEE
Contra CtiDate' /� Y f/ DISTRICT NO. GROUP MAP ' �'l
ACCESSED BY
CITY TEL.NO. BK PG
L1am exempt under Sec. Of the L.A.Co, STATE 5��'� G CL 4
P LICENSE N CLASS
NO. DESCRIPTION Of WORK FEE ��
Plumbing Code and/or Sec. of the FINAL
HOUSE SEWER CONNECTING TO DATE �// ,{�j TION
PUBLIC SEWER ( 6�(/3
VALIDA
B. 8, P. Code for the following reason SEPTIC TANK,SEEPAGE PR OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY y
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License EOXTNFLOCESS CESSPOOL,DDRYWEDLLAMN HOLE �508,5 A
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fession$Code): SEWER OR DISPOSAL SYSTEM #•° ° ° ° 1 0
❑ I,as owner of the property,or my employees with wages as '
their sole compensation, will do the work and the structure ,z e ° 27,5 0
is not intended or Offered for sale (Section 7044, Business f
and Professions Code). OWNER'S Permit $ �, 2 7;5 0 0x
❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONI ACTOR TO
Business and PFOfes$IOns Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ,
1 hereby affirm that there is o construction lending agency SIGNED THIS DAY OF 1
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT
ADORE55
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 IOwS regulating Plumbing,and Sewers,
and hereby authorize representatives of this County to enter
up�Slgn.l
on the
bove-mentioned pro rty for Ins ac
tion purposes.
T
tem Date SEE REVERSE FOR EXPLANATORY LANGUAGE