HomeMy Public PortalAbout10440 LA ROSA DR_Sewer__ r WORKERS' COMPENSATION DECLARATION C ,
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I hereby affirm that I have a certificate, of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 7eAa4zD-
a certified co y'i�fie�re/oi (Sec 3800, L ,_ , CE BDB,REV.B,B., APPLICATION FOR PERMIT
Policy No�2�CLCOmpany ✓/L �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 O p—S. ..- STATION DEPTH
L
COMPENSATION INSURANCE ADDRESS 1
(This section need not be completed if the work involved by the •� � MANHOLE REFERENCE UPPER
LOCALITY .LOWER
permit is for one hundred dollars ($100)or less.) "
NEAREST ` ,, TYPE OF CONNECTION MALENGTHO FROM
I certify that in the performance of the work for which this - clross'ST. ,,,f.�` Y. cuRB. P.L. M.L.To P.L. Y
permit is issued, I shall not employ any person in any manner d
so as to become subject to the Workers' Compensation Laws, t P.C.No. O
OWNER CO.IMP.NO, JOB NO. W
Date Applicant MAIL
ADDRESS !— S , % TRUNK PERMIT NO. ROAD PERMIT NO.
/ INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY TELNO. -o AFFIDAVIT WAIVER EASEMENT RECORD. 0
~
Exemption, you should become subject to the Workers' LEGAL uVt
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR Si.WIDENING 6.
comply with such provisions or this permit shall be deemed /'1 W
revoked. BLOCK TRACT // STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION NO. ON LOT
Se OF BLDGS. PERMIT NO.
hereby affirm That licensed under provisions of Chapter USE OF
SIZE OFLOT NOW
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS - CHARGES
ness and Professions Code, and my license is in full force and
effect. //�' (' T CONTRACTOR CONNECTION CHARGE FEE -
License NU mb�'� SJ Li C.Class /`/ REIMBURSEMENT FEE _ -
y4`/. /J �y ADDRESS
Contract 4�'ta"_ Date ��7 'O �' DISTRICT NO. GROUP MAP POCESSED BY
CITY TEL NO. BK FG
/ z
❑ am exempt under Sec. STATE LIC,
of the L.A.Co. LICENSE NO - k- CLASS
NO. DESCRIPTION OF WORK FEE D� />
Plumbing Code and/or Sec. of the •. FINAL
HOUSE SEWER CONNECTING TO ! DATE G�r�/ S�2 VALIDATION
B. 8 P. Code for the following reason PUBLIC SEWER ! (G aJ
SEPTIC TANK,
SEEPAGE OR -
Pli$AND/OR DRAINFIELD LD FINAL
Date HOUSE SEWER CONNECTING TO BY , .a
PRIVATE DISPOSAL SYSTEM
Signature - CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
hereby affirm that I am exempt from the Contractor's License XFLOSLGE RELEETNCESPOO,DDYWL,MAN OLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ 50 &9A I,as owner of the property,or my employees with wages as -9 ,
their sole compensation, will do the work and the structure
is not intended or Offered for sale (Section 7044, Business .e 0
and Professions Code). OWNERS' Permit $
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE ,2 ° - 27.50
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR i0 T
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. ° 2 7,-L 0 2 U
CONSTRUCTION LENDING AGENCY a A Poo.
9.0 9-8,3
1 hereby affirm that there is a construction lending.agency SIGNED THIS DAY OF 19
for the performance of the work for which this permit is OWNER <• ���q ,�-�
'OWNERS AGENT /
issued (Sec. 3097, GV. C.). ADDRESS •
Lender's Name L
,
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 pr rty for inspection purposes.
Signal of Per te� Date SEE REVERSE FOR EXPLANATORY LANGUAGE