HomeMy Public PortalAbout10405 LA ROSA DR_Sewer__ WORKERS'COMPENSATION DECLARATION C �i
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A644D
a certified Spp thereof (Sec 3800, L�` cEeoB,REy.B,B., APPLICATION FOR PERMIT
Policy N '3/i�/(,Company Oes '
❑ Certified ropy 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 STATION DEPTH
COMPENSATION INSURANCE ADDREss
(This section need not be completed if the work involved by the LOCALITY �� T / MANHOLE REFERENCE UPPER
LOWER
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permit is for one hundred dollars (8100)or less.) LENGTH FROM
NEAREST TYPE OF CONNECTION
certify that in the performance of the work for which this CROs55T. v. NRa P.L. M.L.TO P.L. >
permit is issued, shall not employ any person in any manner d
so as to become sub'ect to the Workers' Com ensafion Laws. �/_yq P.G.NO. O
P, OWNER ,�.� ,� '/ CO.IMP.NO. JOB NO.
N`e'il
Date Applicant �y •� TRUNK PERMIT NO, ROAD PERMIT NO.
ADDREss
AFFIDAVIT' WAIVER EASEMENT RECORD.INSTR.NO. DATE O
NOTICE TO APPLICANT: If, after making this Certificate of afy — TEL.NO. <-p�- �i z� I�
Exemption, you should become subject to the Workers' - V
Compensation provisions of the Labor code, you must forthwith DESCRIPiLION LOT No. HWY.OR ST.WIDENING d
comply with such provisions or this permit shall be deemed w
revoked. BLOCK TRACT ��� STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION NO of SOLOS. PERMIT No. —
SEOFLOT NOW ON LOT ` /O
I hereby affirm that I am licensed under provisions Of Chapter USE of J
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. •� Q CONTRACTOR CONNECTION CHARGE FEE
License NumbLIG Class .C� / ADDRESS REIMBURSEMENT FEE '
Contractor CC79 Dote 7 ��i] DISTRICT NO. GROUP MAP PR ESSED BY
CITY TEL NO. BK PG /J
'"'J LI .
❑ I am exempt under Sec. STATE
Ser.—of the L.A.Co. LICENSE NO. 0.425 [9 y� CL'ASS J
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO �. DATE //' a }�7 VALIDATION
B. 8 P. Code for the following reason PUBLIC SEWER ( 6 a J
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM A
Z p
Signature CONNECT ADDITIONAL BLDG.OR 5 0 1 9.J
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWERPoo '
OVERFLOW SEEPAGE PIT,DRAINFIELD # O O o O 0 -
hereby affirm that am exempt from the Contractor's License fXTN.,CESSPOOL,DRYWELL MANHOLE
Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM 2 o e 2 7,5 0
❑ I,as owner of the property,or my employees with wages as ,'o o 0 2 7.5 0 csi
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business r
and Professions Code). OWNER'S
Permit $
04, 09-83
❑ I, asowner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 7
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C15NTfACTnR TO
Business and PrOfesSlons Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING i0 THE PUBLIC SEWER..
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there is a construction lending agency SIGNED THIS._DAY OF -
for theerformance of the work for which this permit is OWNER OR /
P P 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. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorizerepresentatives Of this County to enter
upon the above-mentioned pro for lnspe ton purposes. -
Signal of Per it Date .SEE REVERSE FOR EXPLANATORY LANGUAGE