HomeMy Public PortalAbout10335 LA ROSA DR_Sewer__ WORKERS' COMPENSATION DECLARATION -
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A6a4D _
a certified co y thereof(Sec. 3800, LoI,ZC , CEBDBIREV.B/BI, APPLICATION FOR PERMIT
Policy No.. ?9�7/Company �' s��'_� 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.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING ��. 2 �� Z 6 �1 STATION DEPTH
COMPENSATION INSURANCE ADDRESS /T
(This section need not be.completed if the work involved by the2 C/ MANHOLE REUPPERFERENCE FERENCE OWER
permit is for one hundred dollars ($100)Of less.) NEAREST TYPE OF CONNECTION
I certifythat in the performance of the work for which this LENGTH FROM
P CROSS Si.• Y. CURB PA M,l.TO P.l. �
permit is issued, I shall not employ any person in any manner 0.
'—
so as to become subject to the Workers'Compensation Laws. / i� P.C.NO, O
OWNER �� CO.IMP.NO. JOB NO. V
MAIL O'er L ` /�, TRUNK PERMIT NO. ROAD PERMIT NO. W.
Date Applicant ADDRESS a G-
> � ti / AFFIDAVIT I WAIVER EASEMENT RECORD,INSTR.NO, DATE O
NOTICE TO APPLICANT: If, after making this Certificate of aTY � rEL.No ,6 V
Exemption, you should become subject to the Workers' LEGAL W
Compensation provisions of the Labor code, you must forthwith HWY.OR ST.WIDENING tL
p p y DESCRIPTION LOT NO.
comply with such provisions or this permit shall be deemed revoked. BLOCK TRASTATE ENCROACHMENT Z Z
LICENSED CONTRACTORS DECLARATION - NO.OF BOGS. 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 CHARGES
nes%and Professions Code, and my license is in full force and
effect. CONTRACTOR ' CONNECTION CHARGE FEE
AooREss
License NumbelC-�:3./J E j Lic.Class S/ REIMBURSEMENT FEE
Contractor /1 ::rz // Date % `L � DISTRICT NO. GROUP MAP P E55ED BY
CITY TEL.NO. BK PG
'7 c� LIC.
❑ 1 am exempt under Sec. STATE of the L.A.Co. LICENSE No. '�p 6 CL
NO,
Plumbing Code and/Or Sec. of the No. 'DESCRIPTION OF WORK FEE At ^�..y
HOUSE SEWER CONNECTING TO _� DATE I __/� .ry/ VALIDATION
B. 8 P. Code for the following reason PUBLIC SEWER r
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ►
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
INFIELD
I hereby affirm that I am exempt from the Contractor's License EO TN.,CESSPOOL.DRYVERFLOW SEEPAGE WEDLLAMANHOLE .-
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE n
fessions Code): SEWER ORDISPOSAL SYSTEM _° 5 0 9.7 A
❑ I,as owner of the property, or my employees with wages as - .e o o a Q
their sole compensation, will do the work and the structure t ,
is not intended or offered for sole (Section 7044, Business
and Professions Code). OWNER'S Permit 8 ,2.° 0 27-50
❑ I, as owner of the property, am exclusively contracting with - AUTHORIZATION TOTAL FEE s
licensed contractors to construct the project Section 7044, ! 0 0 0 2 7, 5
P ( HAVE AT THIS DATE E CONTRACT WITH THE HEREIN NAMED SEWER. RTO
Business and PFOfe5510n%Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING i0 THE PUBLIC SEWER. O p 0.9-83
CONSTRUCTION LENDING AGENCY ,
hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 9�
for the performance of the work for which this permit is OWNER OR /
issued (Sec. 3097, Civ. C.). OWNERS ADEN
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 property for inspection purposes.
Signature of Ppy ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE ..