HomeMy Public PortalAbout10403 LA ROSA DR_Sewer__ WORKERS'COMPENSATION DECLARATION / - - �E
I hereby affirm that I have a certificate of consent to self fls'
insure, or a certificate of Workers' Compensation Insurance, or 7eAa42D
a certified copy thereof (Sec. 3800, Lob�C. > CE 808(REV.B/Bit APPLICATION FOR PERMIT
Policy NoCompany J� ls'j"E� es
❑ 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 _
(This section need not be completed if the work involved by the MANHOLE REFERENCE
UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY ` LOWER
certify That NEAREST TYPE OF CONNECTION LENGTH FROM. P.L.he performance of the work for which this CROSS ST. YCURB PM.L.TO P.L Y
permit is issued, I shall not employ any person in any manner y
so as to become subject to the Workers'Compensation Laws. D.C.NO.
OWNER 1 - CO.IMP.NO. JOB NO, 0
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Dale Applicant ADDRESS 7 �y C
NOTICE TO APPLICANT: If, after making this Certificate ofCITY TEL.NO.�� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.VO. DATE O
Exemption, you should become subject to the Workers' LV
Compensation provisions of the Labor code, you must forthwith LEGAL
P P Y DESCRIPTION LOT NO,
comply with such provisions or this permit shall be deemed HWY.OR Si.WIDENING N
revoked. BLOCK TRACT �� [lV STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION NO.OF BLOGS. PERMIT NO.
I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT y,
9 (commencing with Section 7000 of Division 3 of the Busi- USE OF
( 9 )
ness and Professions Code, and my license is in full force and BUILDINGS CHARGES
effect. / /J � CONTRACTOR CONNECTION CHARGE FEE
l
be
License NUml? .�h LIC.CIasS ADDRESS REIMBURSEMENT FEE '
_ be
Ca n t r 0 C t Date 9+ DISTRICT NO. GROUP MAP ROCESSED 8P i
EQ3 CITV /� iEL.NO. BK PG
STATE . 04v�, (_ LIC.
am exempt under Sea of the L.A.Co. LICENSE No CLASS
F go
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FI L
HOUSE SEWER CONNECTING i0 PATE //� �� VALIDATION
B. & P. Code for the following reason
PUBLIC SEWER ( (P
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL
Dote HOUSE SEWER CONNECTING TO ABY _ CJ
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I
re OVERFLOW SEEPAGE PIT,DRAINFIELD E%TN.,CESSPOOL,DRYWELL,MANHOLE exempt from the Contractor's License
Law for the following reason (Seaton 7D31.5, BUI$ne$$and Pro- ALTER.REPAIR OR ABANDON HOUSE
fessions Cade): SEWER OR DISPOSAL SYSTEM 5 0 9.4 A
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure 'k o o e It 1 0
is not intended or offered for sale (Section 7044, Business • '
and Professions Code), OWNER'S Permit S 2 o - 27.50
❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATIONTOTAL FEE �T
licensed contractors o construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C NTR CTO TO . . . 2 7.5 0 5
BUSIne$$and Professions Code), CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. '
CONSTRUCTION LENDING AGENCY , 0909-83
1 hereby affirm that there is a Construction lending agency SIGNED THIS DAY OF _
for the performance of the work for which this permit is OWNER
issued (Sec. 3097, Civ. C.). OWNERS AGENT
tender's Name ADDRESS
Lender's Address '
I certify that 1 have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and Store laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-mentioned top y for inspe tion purposes. '
Sign atu of Per; e� Date SEE REVERSE FOR EXPLANATORY LANGUAGE