HomeMy Public PortalAbout10415 LA ROSA DR_Sewer__ WORKERS' COMPENSATION DECLARATION 1T,
I hereby affirm that I hove a certificate of.consent to self
insure, or a certificate of Workers' Compensation Insurance, or 76A6 21) -
a certifiepy thereof(Sec. 3800, L , CEBOB(REV.B/B„ . APPLICATION FOR PERMIT
Policy Nc?/W' 7/Company LE� ®s
❑ 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 / /J
COMPENSATION INSURANCE ADDRESS STATION DEPTH
(This section need not be completed if.the work involved by the MANHOLE REFERENCE UPPER
LOCALITY �-v-' LOWER
permit is for one hundred dollars ($IOD) Or less.) NEAREST /� TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSSST. '1 " V. CURB PL. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner d
so as to become subject to the Workers' Compensation Lows. y P.C.No. O
P OWNER Co.IMP.NO. JOB NO. V
Date Applicant
ADDRESS It1� ! - TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after making this Certificate Of _ AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE O
g
CITY
TEL.NO. ���_ I.-
Exemption,
Exemption, you should become Subject o the Workers' LEGAL pi
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING d
comply with such provisions or this permit shall be deemed H
revoked. BLOCK TRACT �4'�d STATE ENCROACHMENT z
. .
LICENSED CONTRACTORS DECLARATION
SIZE OF LOT NOOF SLOGSPERMIT NO,
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 Bus, &llmINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. �/ CONTRACTOR CONNECTION CHARGE FEE
License Numb _ rr yer Li0. Class— j ADDRESS 'Le
REIMBURSEMENT FEE
9'
Contracigir� 2 DISTRICT NO. GROUP MAP PR ESSED BY
Y-'97 Date crzv TEL.NO.
STATE ��} ! UC. BK PG
❑ am exempt under Sec. Of the L.A. Co. LICENSE NO Z41 19— CLASS i'1 �3'
NO. DESCRIPTION OF WORK FEE r
Plumbing Code and/or Sec _ of the BNAL
HOUSE SEER CONNECTING i0 pgiE / VALIDATION
B. 8 P. Code for the following reason PUBLIC SEWER
TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License EEXINFLOCESSSEEPAGE
OOi DRVWEuAMANHDOLE
Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 5 0 9.2 A
fessions Code): SEWER OR.DISPOSAL SYSTEM
❑ I,as Owner of the property,or my employees with wages as # o o e e O
their sole compensation, will do the work and the structure '
I$ not intended Or offered for sale (Section 7044, Business P e e 27.T50
and Professions Code). OWNERS Permit $
AUTHORIZATION
L] 1, as owner of the property,am exclusively contracting with TOTAL FEE - It 0 0 2,�..5
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED eONTkACFOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED ExISTiNG DWELLING TO THE PUBLIC SEWER. 09.0 9'-83
CONSTRUCTION LENDING AGENCY [[��3.. ,
I hereby affirm that there is a construction lending agency SIGNED THIS -DAY OF 144
for the performance of the work for which this permit is owNERoR
issued (Sec. 3097, Civ. C.). OWNERS qGE
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 lows regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the bove-mention d wParty f r inspection purposes.
Signature e e Date SEE REVERSE FOR EXPLANATORY LANGUAGE .