HomeMy Public PortalAbout10465 LA ROSA DR_Sewer__ WORKERS'COMPENSATION DECLARATION 76A6420 /7
CE 806 (2-80) APPLICATION FOR PERMIT rylull
1 hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800. LaaCOUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No: Company L«d:2 1�-
lS/-3 �21—,ft t, FOR APPLICANT TO FILL IN CONNECTION DATA
ElCertifie copy is hereby furnished.
BUILDING ® e� STATION yJ /JJ7� DEPTH �/
ADDRESS • `+
•••Certified copy is filed with the c unty buildin inspection �r u
yCpart eDI. _ MANHOLE REFERENCE �f00 A ' f
LOCALITY
✓✓✓//J LOWER
D3 2 �Applica Gee NEAREST TYPE OF CONNECT LENGTH FROM
CERTIFICATE OF EXEMPTION FROM VIIcRoss sr. Y.
CURB
P.L. M.L. TO P.L.
CERTIFICATE OF EXEMPTION FROM V
COMPENSATION INSURANC - P.c.WP. rvo.
ONER CO. IMNO. IUB NO. 3
MAIL
(This section need not be completed If the work involved ADDRESS /�/`��PJ TRUNK PERMIT NO. ROAD PERMIT NO. a
by the permit is for one hundred dollars ($100) or less.) AFFIDAVITWANeR E SEME ,CORD INSTR N DATE O
CITY L. NO. / 7 (�j ` U
1 certify that in the performance of the work for which this LEGAL
permit is issued, 1 shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ET. WIDENING cc
so as to become subject to the Workers' Compensation Laws. 0
BLOCK TRACT STATE ENCROACHMENT
PERMIT
Date Applicant 'No. OF SLOGS. NO. LU
NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF LOT O NOw ON LOT y
Exemption, you should become subject to the Workers' USE DIF �� 'HwnGes Z
BDILDINGs
Compensation provisions of the Labor Code, you must forth-
with comply with such CONNECTION CHARGE FEE
p y provisions or this permit shall be CONTRACTO
deemed revoked.
REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that 1 am licensed under provisions of Chapter STRICT NO. GROUP MAF P. CTR i EY
9 (commencing with Section 7000)of Division 3 of the Busi- CITY TEL. rvo. _�( / J t��/
ness and Professions Code, and my license is in full force and STA
NO. �6 fr 'LASS
effect. NO. DESCRIPTION OF WORK FEE
o?� S „ EWE CONNECTING TO FINAL VALIDATION
License Number ic.Class�J l/ m _PUBLICEWE DATE
IC'
R.
O r f Dale s Z� O TSTAND/DR o DN FINAL
HOUSE SEWER DPRIVATE RY
I a ex pt from the licensing requirements as I am a CONNECT ACONNECTING R
DTI ONA,CSE,Coc.o
lice sed at
or a registered professional engineer Dose SEWER
acting in my professional capacity (Section 7051, Bus SEB FADE 'IT.CTR•
iness and Professions Code). -W.11.eL,C ALTER. REPAIR OR
sseABANDON
M HOUSE
DISPOSALSEWER OR
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNER'S Permit II
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATIONTOTAL FEE
ness and Professions Code): CONTRACTI HAVE AT THIS DATE A W ;20550A
I, as owner of the property. will do the work and the
ro.HE rUeuc SEWER. EovE DESCRIBED EL
structure is not intended or offered for saleSIGNED THIS(Section DAV OF 19 # • • • • 0
„
7044, Business and Professions Code). OWNER CTR
HENS• 8,00
CONSTRUCTION L17NDING AGENCY
1 hereby affirm that there is a construction lending agency o e e e 1 R 0 0z
for the performance of the work for which this permit is D
issued (Sec. 3097.Civ.C.). 03.2 9r—8
Lender's Name
Lender's Address
1 certifv that 1 have read this application and state that the
above information is correct. 1 agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers.
and hereby authorize representatives of this County to enter
upon thementioned property to inspe�purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ermine' ate