HomeMy Public PortalAbout10430 LA ROSA DR_Sewer__ WORKERS'COMPENSATION DECLARATION / l r
I hereby affirm that I have o certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
Pol cy fNod `, opy 1h�ZLCompo�z .�- —�� o,�B(REV.8/81 APPLICATION FOR PERMIT
❑ Cerfified copy is hereby furnished. SEWER • SEWAGE DISPOSAL
❑ Certified copy is filed With the county building inspection COUNTY OF LOS ANGELES - BUILDING AND SAFETY
department.
Dote - Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS -3(J L �,� STATION DEPTH
(This section need not be completed if the work involved by the IOCAIIi QMANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOWER
I certify that in the performance of the work for which this CROSS Sr - Tvvf of CONNECTION M.I.LENGTHFROM
Com/ / Y. - CURB PL M. TOP.L. I'
permit is issued, I shall not employ any person in any manner �p// P c NO. 1
so as t0 become subject to the Workers Compensation Laws. OWNER +(/"'+/ CO.IMP,NO. JOB NO. 0
MAIL
Date Applicant
ADDRESS '! Lr�+ �cc—�/ TRUNK PERMIT NO. ROAD PERMIT NO. dr
—R AfFDAVIi WAIVER EASEMENT RECORD.INSiR.NO. DATE O
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.No. 6„��.•�X
Exemption, you should become subject to the Workers' LEGAL W
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING a'
comply with such provisions or this permit shall be deemed N
revoked. BLOCK TRACT STATE ENCROACHMENT - Z
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO,
�j
I hereby affirm that I Se USE OF licensed under provisions of Chapter SIZE OF LOT NOW ON LOT
I S
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. CONTRACTOR ��� CONNECTION CHARGE FEE
9/
License NumbeF-sLic Class /S/
�i ADDRESS REIMBURSEMENT FEE
C'OntroctO�E--e�. Dale, CITY TEL.NO. D157RICT NO. GROUP BK PG,MAP PPOCESSED BY
ElI am exempt under Sec. of the L.A.Co. LICENSE NO. 2 ! UClAC Ss '1�5
t
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK HE T AOHOUSE SEWER j-�'3 VALIDATION
PUBLIC SEWER CONNECTING i0 ! DATE FOO J
B. 8 P. Code for the following reason SEPTIC 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
C O
hereby affirm that am exempt from the Contractor OVERFLOW SEEPAGE PIT,DRAINFIELD
Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE 'F J
Law for the following reason (Secton 7031.5, BWSness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
0 0 0 0 1 0
❑ I,as owner of the property,or my employees with wages as '
their sole compensation, will do the work and the structure - Q'o 02,7.5 0
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit Is •R'R u Z 7.5 0 6
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE L
licensed contractors to construct the project (Section 7044; 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ONi ACTOR i0 0.9 09-83
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 SIGNEDTHIS DAY OF 19_
for the performance of the work for which this permit is OWNERSOR
AG
issued (Sec. 3097, Civ. C.). OWNERE
ADDRESS
—
Lender's Name '
Lender's Address
I certify that I hove read this opplication 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 df this County to enter
upon the above-mens ioned grope for inspection purposes. "
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Signotur Pe it a Date SEE REVERSE FOR EXPLANATORY LANGUAGE