HomeMy Public PortalAbout10355 LA ROSA DR_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self ILl4
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certified co thereof (Sec 3800, Lob—C.,.�y-- CEBDB,RE°.B,BI) APPLICATION FOR PERMIT
Policy No 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' FC,TY ,.,—
STATION DEPTH -
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the L MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOWER
'/ TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this �'� �/r Y. CURB P.L. M_I.TO PA Y
permit is issued, I shall not employ any person in any manner P.t.No.
so as to become subject to the Workers' Compensation Laws. CO.IMP,NO. JOB NO.
u
TRUNK PERMIT NO. ROAD PERMIT NO, cc
Date Applicant ^ /
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
.NOTICE TO APPLICANT: If, after making this Certificate of is TEL.NO. - V
Exemption, you should become subject to the Workers' LEGAL _ to
Compensation provisions of the Labor code, you must forthwith CRIPTION LOT No. Hwv.OR BT,WIDENING
comply with such provisions or this permit shall be deemed ] rn
revoked. BLOCK TRACT [/ STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION SIZE OF LOT No.of BUDGE. PERMIT NoNOW ON LOT .
_ �(r
I hereby affirm that I am licensed under provisions of Chapter USE OF fir
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 Numberz��`V LIC.Class �j ADDRESS REIMBURSEMENT FEE
COntraCtar/�Lb9 �� Data /-'/� DISTRICT NO. GROUP MAP P ESSFD BY
CITY 'TEL NO. BK PG
❑ I am d
exempt uner Sec. othe L.A.Co.
11 LC O
P f STATE
hCLICENSE NO. G�j—t�h CLASS
- r
Plumbing Code and/pr Sec. of the NO. DESCRIPTION OF WORK FEE TDATE
HOUSE SEWER CONNECTING TO G.I _IALIDATION
B. 8 P. Code for the following reasonPueuc srwERSEPTIC TANK.SEEPAGE.PIT ORPITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING i0 `J I
PRIVATE DISPOSAL SYSTEM
Signature _ CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
y P OVERFLOW SEEPAGE PIT, LL,MANHOLE -9509.5A
hereby affirm that I am exem t from the Contractor's License EXTN_CESSPOOL,O PIT,DR MNHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE .A _
fessions Code): SEWER OR DISPOSAL SYSTEM # o o•a o 0
❑ I,as owner of the property,or my employees with wages as $.
their sole compensation, will do the work and the structure ,� " ^ 2750
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS _ Permit 8 OAITIR
'ego a '2'],S O
❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE r
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED N 0'9 0 9-8,3
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 ` 79� - -
for the performance of the work for which this permit is OWNER z�
OWNERS A R
issued (Sec. 3097, Civ. C.). -
ADORE
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 lows regulating Plumbing and Sewers, _
and hereby authorize representatives of this County,to enter -
upon/thee above-mentioned prop.rty for inspection purposes.
Signature erm ittee to SEE REVERSE FOR EXPLANATORY LANGUAGE