HomeMy Public PortalAbout10410 LA ROSA DR_Sewer__ WORKERS' COMPENSATION DECLARATION �� a
I hereby affirm that I have a certificate of consent to self '
insure, or a certificate of Workers'Compensation Insurance, or lanea3D
a certified co y��t�hh��greoo�f (Sec. 3800, La � � CE 508 IREY'a/811 APPLICATION FOR PERMIT
Policy Na zv;;Company
❑ 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 ® STATION DEPTH
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involvedby the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) Locnuiv - 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 M.L.P.C.No. 0.
so as to become subject to the Workers Compensation Laws. OWNER /� 1G�J Co.IMP,NO, JOB NO. V
MAIL
Date-Applicant
ADDRESS LL cam,/•� TRUNK PERMIT NO. ROAD PERMIT NO. (y+
NOTICE TO APPLICANT: If, after making this Certificate Of CITY G TEL NO, G�[7JC45� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE O
rP V
Exemption, you should become subject to the Workers' LEGAL W
Compensation provisions of the Labor code, you must forthwith PC
T NO: HWY.OR ST.WIDENING N
comply with 'such provisions or this permit shall be deemed ,�
revoked. ACT G � STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION No,OF BLDGS- PERMIT NO.
NOW ON LOT ��
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the BUSH CHARGES
.nesS and Professions Code, and my license is in full force and
effect. CONNECTION CHARGE FEE
License Nu.my�ber Lic.Class 251/ REIMBURSEMENT FEE
COntraCfOf �1 Date / % O� DISTRICT NO, GROUP MAP P ESSED BY
CITY p TEL.NO. BK PG
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. �f�(J CLASS f -3
Plumbing Code and/or Sec. of the No. DESCRIPTION OF WORK FEE F AL
HOUSE SEWER CONNECTING TO DATE / VALIDATION
B. 8 P. Code for the following reason A PUBLIC SEWER 7
SEPTIC TANK,SEEPAGE PIT OR FINAL
PO AND/OR ORAICONNECTING
HVs
Dote HOUSE SEWER CONNECTING iO BY V
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK O HOUSE SEWER
OVER.,CES SEEPAGE PIT,ELL, INFIELD
MANN
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRvwfu,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE !L G O o
fessions Code): SEWER OR DISPOSAL SYSTEM J O.
❑ I,as owner of the property, or my employees with wages as
their sole compensation, will do the work and the structure # 0 0 o e p
is not intended or offered for sale (Section 7044, Business '
and Professions Code), LAUTHORIZATION
NER'S Permit $ 2 ° - 27.50
❑ 1,as owner of the property, am exclusively contracting with ION TOTAL FEE j 010 0 2 7.5 0 czi
licensed contractors to construct the project (Section 7044, THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ' QBusiness and Professions Code). HE ABOVE DESCRIBED ExISTING DWELLING TO THE PUBLIC SEWER. ORO9_U3
CONSTRUCTION LENDING AGENCY QIhereby affirm that there is a construction lending agency IS DAY OF I�Sfor the performance of the work for which this permit is E
issued (Sec. 3097, Civ. C.).
Lender's Name -
(
Lender's Address
I certify that I have read this application and state that the i
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers, j
and hereby authorize representatives of this County to enter
Upon the above-mentioned property for inspection purposes. '
S gna ure of P ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
I