HomeMy Public PortalAbout10345 LA ROSA DR_Sewer__ WORKERS'COMPENSATION DECLARATION IT" \
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 7eAe41D
a Certified y thereof (Sec. 3800, Lobb�C•.) CE 808(REV. APPLICATION FOR PERMIT
Policy No,�ss�//Compony L .2a� i'7d9�a,7 Os
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF ANGELES BUILDING AND SAFETY
department.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
ADDRES /�� i�S STATION DEPTH
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the ' / T MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($1,00)or less.) LOCALITY L-LSL LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L TO P.L. }
permit is issued, I shall not employ any person in any manner - P.C.NO, tL
so as to become subject to the Workers Compensation Laws. OWNER CO.IMP..NO, JOB NO. O
MAILU
Date Applicant
ADDRESS TRUNK PERMIT NO, ROAD PERMIT NO. Q[
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'
Compensation provisions of the Labor code, you must forthwith LEGAL W
P P DESCRIPTION LOT NO. HWY.OR Si.WIDENING d
comply with such provisions or this permit shall be deemed ?7 /'� W
revoked. BLOCK TRACT_ 5/ L/ STATE ENCROACHMENT z
LICENSED CONTRACTORS DECLARATION No,OF BLDGS. PERMIr 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
ness and Professions Code, and my license is in full force and /
effect. CONTRACTOR ` CONNECTION CHARGE FEE
License Numbe L-� 4� Lic.Classy p ADDRESS REIMBURSEMENT FEE
COntrc ' I Date ; % DISTRICT NO. GROUP MAP PR ESSED BY
CITY TEL.NO. 8K PG
❑ am exempt Sec. of the L.A.Co. STATE -7 P/ y��i� uc / '3
P LICENSE NO, O_'"yU C1A55 �°
NO. DESCRIPTION OF WORK FEE
Plumbing Cade and/or Sec. of the TE -/
HOUSE SEWER PUBLIC SEWER CONNECTING TO f DATE ! � VALIDATION
B. 8 P. Code for the fallowing reason ! r
SEPTIC TANK,SEEPAGE OR
PITS AND/OR DRAwFIEUD Lp FINAL
Dote HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM \1
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER -
OVERFLOW SEEPAGE PIT,.DRAINFIELD G n c q
I hereby affirm that I am exempt from the Contractors License EXTN. 5 0 4.U A
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM # e o o O 1 0
❑ I, as owner of the property,or my employees with wages as G+o 0 2 7. 50
1 5 0
their sale compensation, will do the Work and the structure
I% not intended or offered for sale (Section 7044, Business +
and Professions Code). OWNER'S Permit _ 8i o 0 0 27,506
❑ 1, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE - - Q'Q'0 9-83
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED N"NTRACTOR 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 19 ►"'
for the performance of the work for which this permit is OWNER OR -
OWNERS AGENT
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. Iagree 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 roperty or ins ection purposes.
Signature ermi a Date SEE REVERSE FOR EXPLANATORY LANGUAGE