HomeMy Public PortalAbout10425 LA ROSA DR_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self - 7151
insure, or o certificate of Workers' Compensation Insurance, or 76A6 21)
a certified c``Eop�py t�h�yer�eo�f (Sec. 3800, Lab C. CE 808(REV,P/BI) APPLICATION FOR PERMIT
Policy No. Company OPs
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS dF� _ STATION DEPTH
(This section need not be completed if the work involved by theC/ MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($)00)or less.) LOCALITY - LOWER
- FROM
I certifythat in the performance of the work for,which this
NEAREST TYPE OF CONNECTION M L TO P.L.
P CRO55 Si. Y. CURB P.L. M.l.i0 P.L. CL
permit is issued, 1 shall not employ any person in any manner NO. o
so as to become subject to the Workers'Compensation Laws. -
OWNER JOB�+� 6�� CO.IMP.NO. JOB NO.
V
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS �—r—c-G� 0
NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE O
CITY ✓� TEL NO. ��� (a u
Exemption, you should become subject to the Workers' LEGAL
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 •�/
revoked. BLOCK TRACT STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION NO. ON LOT OF BLDGS. PERMIT NO.
(R•
hereby affirm that SIZE OF LOT NOW am licensed under provisions of Chapter USE OF /
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. ^J / CONTRACTOR CONNECTION CHARGE FEE
License NU.m�be'rC/> L'e Lic.Class ADDRESS REIMBURSEMENT FEE
ContrcctA&_A1a Date CITY DISTRICT NO. GROUP MAP PR E55ED BY
CITY ,�j TEL. q BK PG t
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. 4E7:1e:!> �/ CLASS .0/"" J
NO. DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the DATE '
,EIDUSE SEWER CONNECTING TO / DATE VALIDATION
B. 8 P. Cade for the following reason Pu9uc sENKR
17
SEPTIC TANK,SEEPAGE PIT OR FINAL
Date PITS AND/OR DRAICONNECTING
HOUSE SEWER CONNECTING i0 BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK O HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License oTN_CESSPOOL.DRVWEDLL,MANHOLE '
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE -
fessions Code): SEWER OR DISPOSAL SYSTEM - <
El 1,as owner of the property,or my employees with wages as 5 0 9. A
their sole compensation, will do the work and the structure
IS not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit $ �' 20 2.7.5 0
0
L1 1,I,as owner of the property,am exclusively contracting with TOTAL FEE
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON RACTOR TO u•u u 27.5 0 L
Business and Professions Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY- GJ' , 00. 09—83
1 hereby affirm that (here is a construction lending agency SIGNED THIS DAY OF / IALS
for the performance of the work for which this permit is OWNER OR
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 authorize representatives of this County to enter -
upon/thee above-mentioned property to inspe�cttlio/n,purpo�Ses,
Signotur ermitte Date SEE REVERSE FOR EXPLANATORY LANGUAGE