Loading...
HomeMy Public PortalAbout10435 LA ROSA DR_Sewer__ WORKERS'COMPENSATION DECLARATION C Q I hereby affirm that I have o certificate of consent to self r LI IS insure, or a certificate of Workers' Compensation Insurance, or TeAm20 a certified co-y thereof (Sec.3800, Igo CE BOB(REV.B/Bq APPLICATION..,FOR PERMIT Policy Na. } Companyc�/�fc ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filedtwith the county building inspection - COUNTYOFLOS ANGELES BUILDING AND SAFETY department Dale Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING �, STATION DEPTH COMPENSATION INSURANCE ADDRESS _s (This section need not be completed if the work involved by the ' MANHOLE REFERENCE LOWER, permit i5 for one hundred dollars ($100) or less.) LOCALITY 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 PL. Y permit is issued, I shall not employ any person in any manner �_ O on so as to become sub'ect to the Workers' Compensation Laws. P.c.No. P OWNER CO.IMP.NO. JOB NO. V MAIL / TRUNK PERMIT NO. ROAD PERMIT NO, 09 Date ADDRESS Applicant 4 S /c>� ' . NOTICE APPLICANT: If, after making this Certificate of CITY ret.No. ��� U Exemption,n, you should become subject to the WorkeWorkers' LEG AFFIDAVIT WAIVER EASEMENT RECORDINSTR.NO. DATE O l w Compensation provisions of the Labor code, you must forthwith- DESCRIPTION LOT NO. / HWY.OR Si.WIDENING 1 comply with,such provisions or this permit shall be deemedBLOCK TRN CT— revoked. Ar•1 PERMIT N� � (/ STATE ENCROACHMENT Z LICENSED CONTRACTORS DECLARATION No.of SLOGS. SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF - Sf 5_1 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 License Number—,�--�-1,/' Lic. loss '13/ ADDRESS REIMBURSEMENT FEE Contracte_?:i / •O Date �J'—3 CITY TEL NO. DISTRICT NO. GROUP MAP PR SEED BY JJ BE PG STACLASS,,rr!' LIC. © �- ❑ I am exempt under Sec. of the L.A.Co. uCENSE No. �Pi u�' ss Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE NAL HOPUBLIC SEUSE SEWER CONNECTING TO DATE WER VALIDATION B. 8 P. Code for the following reason —IJ SEPTIC TANK;SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD � J Date HOUSE SEWER CONNECTING TO BY, PRIVATE DISPOSAL SYSTEM V Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION - WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD 5 ,A I hereby affirm that I am exempt from the Contractors License EXTN.,CESSPOOL,DRYWELL,MANHOLE - Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE - ,N a D 1 m 1 0 fessions Code): SEWER OR DISPOSAL SYSTEM H ❑ I,as owner of the property,or my employees with wages as 2�e e 27,150 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business is u R 2 7,'S and Professions Code). OWNERS Permit $ �r ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON ACTOR i0 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY ' fhereby affirm that there is a construction lendS lending agency SIGNED THIS DAY OF I or the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT �'.3, ADDRE 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 above-mentioned proper for inspection purposes. Signature of P ittee / Date SEE REVERSE FOR EXPLANATORY LANGUAGE