HomeMy Public PortalAbout10325 LA ROSA DR_Sewer__ WORKERS' COMPENSATION DECLARATION r_
I hereby affirm that I have a certificate of consent to self /. X
insure, or a certificate of Workers'Compensation Insurance, or 76A6a21)
a certified copy thereof.(Sec. 3800, La ��i- CEB08(REV.8181 APPLICATION FOR PERMIT
Policy No;�, L/Company '7G�rt� Bs
❑ 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 ® > O STATION DEPTH
COMPENSATION INSURANCE ADDRESS G
(This section need not be completed it the work involved by the MANHOLE REFERENCE UPPER
Permit is for one hundred dollars ($100)or less.) LOCALITY -� _ f LOWER
I certify that in the performance of the work for which this CROs ST. �e=/C� TYPE OF CONNECTION MFL TO FROM
- Y. CURB P.L. M.l.i0 P.L. IL
permit is issued, I shall not employ any person in any manner d
so as to become subject to the Workers' Compensation Laws. JOB NO. O
I P OWNER � � CO.IMP.NO. JOB NO. V
'NAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS � ?07�//
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE O
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.No.
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor code, you must forthwithDESCRIPiLLU
ION LOT NO. HWY.OR ST.WIDENING 1
comply with such provisions or this permit shall be deemed f'] W
revoked. BLOCK TRACT C/ STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION NO.OF BmcS: 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- BUILDINGS cHAROEs
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR CONNECTION CHARGE FEE
License NumI ber D K`'�/Lic.Class S/ ADDRESS REIMBURSEMENT FEE
Conhact__ ' — ,
/�� � Date /`/ rCITY TEL NO. 0 BK PG DISTRICT NO, GROUP MAP PRPSSED BY
STATE LIC.
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS
RK DESCRIPTION OF WOFEE
Plumbing Code and/or Sec. of the NO. DATE '
HOUSE SEWER CONNECTING i0 ' DATE !/'r�l,? VALIDATION
B. 8 P. Code for the following reason PUBLIC SEWER c?r(ca u
SEEYIC TANK,SEEPAGE PIT OR
Date FINAL �)
PITS AND/OR DRAINFIEID
HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR , 1
OWNER-BUILDER DECLARATION WORK To HOUSE SEWER
OVERFLOW SEEPAGE PIT DRAINFIELD
1 hereby affirm that I Can exempt from the Contractor's License EXTN.;CESSPOOL ORYWEIL.MANHOLE
Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE '
fesslons Cade): SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as ' 509.89
their sole compensation, will do the work and the structure # 0 0 o a 1 0
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit S 21-.0 27.50
El 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C NT ACT R TO _ `6'0 o 27,506
Business and Professions Code). 1 CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. .
CONSTRUCTION LENDING AGENCY , 0 9. 0 9 -8 3J
1 hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 1
for the performance of the work for which this permit is OWNER OR
OWNERS AGES
issued (Sec..3097, Civ. C.).
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 authorize representatives of this County to enter
upon the
above-mentioned prop rt r�in,s�pfe/c�tJion purposes.
Signature ermitte Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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