HomeMy Public PortalAbout10330 LA ROSA DR_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent_to self II
insure, or a certificate of Workers Compensation Insurance, or ]EAt4zD tttSSS
acerIfied cop thereof (Sec. 3800, E �f .- CE BOB(REV.B,B❑ APPLICATION FOR PERMIT
Policy Na.lr/� Company , •/?; Os
❑ 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' BuuowG ,_ O STATION DEPTH
,.�
COMPENSATION INSURANCE ADDRESS doff'
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) NEARESv LOWER
I certify.that in the performance of the work for which this CROSS ST. ¢.G,�i TYPE OF CONNECTION LENGTH
Y. CURB fll. M.L.i0 P1.P.L. Y
permit is issued, I shall not employ any person'in any manner 6
so as to become subject to the Workers'Compensation Laws. PC.NG. O
OWNER MAIL `�/ CO.IMP.NO. JOB NO. u
ADDRESS (i4�T.c�/ TRUNK PERMIT NO.
Date Applicant - ROAD PERMIT NO. cc
f / �r AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO, DATE O
NOTICE TO APPLICANT: If, after making this Certificate of CITY ` TEL NO. � V
Exemption, you should become subject to the Workers' LEGAL / :u
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. /7(� HWY,OR ST.WIDENING
comply with such provisions or this permit shall be deemed /��� W
revoked. BLOCK TRACT / STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION NO.OF SLUGS. PERMIT NO.
4
hereby affirm that I Se USE OF SIZE OF LOT NOW ON LOT
licensed under provisions of Chapter S
-9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and -
effect. coNTRAaoR
CONNECTION CHARGE FEE
Li cense Num bar�l-'+/S/� � LiC Class } ADDRESS �''�'� REIMBURSEMENT FEE
Contract.�wt/ / Date /f.�•` : n� DISTRICT NO. GROUP MAP PR ESSED BY
CITY TEL.NO.
_ / BK PG
El am exempt under Sec. of the L.A.Co. S ATE No. Cwt>��` c ASS �� _
Plumbing Code and/or Sec. ofthe NO' DESCRIPTION OF WORK FEE FINAL ,
HOUSE SEWER CONNECTING TO DATE
B. 8 P. Code for the following reason PUBLIC SEWER s 'l�-d s VALIDATION
SEPTIC TANK,SEEPAGE PIT OR FINAL /
PITS AND/OR DRAINFIELD
Dote HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ►
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER S H.6 A
,
hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.$, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE o o e e 0
fessions Code): SEWER OR DISPOSAL SYSTEM ,
❑ 1,as owner of the property,or my employees with wages as Q o o 2.7• rO 0
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business 0
and Professions Code). OWNERS Permit $ �, .%a ,- 23,506
❑ 1, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 222 4Z 09. 09-8.3
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED NT CTO 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 p 5
for the performance of the work for which this permit is OWNER
ORie�� A T
issued (Sec. 3097, Civ. C. OWNERS AGENT
ADDRESS ez
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 IT ave-mentioned property for inspection purposes.
P
Signatu f e a ,Date SEE REVERSE FOR EXPLANATORY LANGUAGE