HomeMy Public PortalAbout10420 LA ROSA DR_Sewer__ WORKERS'COMPENSATION DECLARATION [ 1 �,I
I hereby affirm that I,hove a certificate of consent to self LI IS
insure, or a certificate of Workers' Compensation Insurance, or 76Ae<21)
acertified co ter;Comc. 3800, L ) CE BoB(REV.8/811 APPLICATION FOR PERMIT
Policy No„�>��%i Company ���J��'?t?s� 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,
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS Ov°
(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
NEAREST / TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST, Y Y. CURB A 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 Laws. P.C.No, O
OWNER ,p�U'C� CO.IMP.NO. JOB NO. V
MALL .� Gs 6 � TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS L�
AfFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE Q
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.No. V
Exemption, you should become subject to the Workers' LEGAL
DEEY
Compensation provisions of the Labor code, you must forthwith xR1Pr1oN LOT No.
HWY.OR ST.WIDENING N
IL
comply with such provisions or this permit shall be deemed ��//'
revoked. BLOCK TRACT _U Z! STATE ENCROACHMENT ' ?
LICENSED CONTRACTORS DECLARATION No.OF SLUDGE. PERMIT NO.
Section
OF LOT NOW ON LOT ✓
hereby affirm that licensed under provisions of Chapter USE OF .J
9 (commencing with Section 7000) of Division 3 of the BBUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. 7 �/ CONTRACTOR CONNECTION CHARGE FEE
License Number,?Z�Y6 / LIC.Class ADDRESS REIMBURSEMENT FEE'
Date 7 DISTRICT NO. GROUP P ESSED B
COntra[1a�� _ CITY - . Y
/1 BK PG =4
❑ am exempt under Sec. of the L.A.Co. LICENSE NO. r C A55 i3 yyy�///''����•[—
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE NAL /•�
HOUSE SEWER CONNECTING TO ' DATE r''r/�-, VALIDATION
B. 8 P. Code for the following reason PUBLIC SEWER i
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY V�
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLUG.OR Poo.DECLARATION WORK TO HOUSE SEWER 5 1 Q 5 A
I hereby affirm that am exempt from the Contractor OVERFLOW SEEPAGE PIT,DRAINFIELD s License EXTN.,CESSPOOL.DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 0 0 0 0 1 0
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as o - 27.50
their sole compensation,'will do the work and the structure o o e 2 ], 5 0v
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit g572
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE - 0909-83
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEDONT ?041 ?
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 TMS DAY OF 19
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGEN
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 authorize representatives of this County to enter
upon the above-mentioned pro e_rty four i/ns/pectionn purposes.
5ignatur f Per fee Date SEE REVERSE FOR EXPLANATORY LANGUAGE.