HomeMy Public PortalAbout9612 LA ROSA DR_Sewer__ WORKERS'COMPENSATION DECLARATION
I- I,heresy,affirm that.l. have a certificate of consent.to self
IYisu`re o$certificate of Workers'Compensation Insurance, or 76A842D " -
a,certifled copy thereof(Sec. 3800, Lab C.) 92-002 DPW s.se APPLICATION FOR PERMIT"
Policy No " Company -
•;❑ Certified copy is hereby famished. + SEWER::- SEWAGE DISPOSAL,
❑ Certified-copy is filed with the county;building inspection - COUNTY OF LOS ANGELES BUILDING AND SAFETY �' r• •.-
department. £',' +• -- -
F,1" -.Date - Appliconi FOR APPLICANT TO FILL IN - ' - .F. - - CORRECTION DATA _
CERTIFICATE,OF,EXEMPTION FROM WORKERS'.',.. BUILDING
stanoN DEPTH
,. COMPENSATION INSURANCE r., ADDRESS I L-. '
(This sectionineed not be completed if the',work involved b the - - _._ -- - - UPPER
_. Y MANHOLE REFERENCE"- - -
permit a for onehundreddollars(E100)',or less ) , ,--- Locnury L I C' er^� _ LOWER
NE
RAREST - TYPE OF CONNECTION- LENGTH FROM
I..certify that -in�the performance of the.work for which chis - caoss sT. I Cit - Y. _Cave P.L. M.L.ioD.L. '
permit is issued;�l•shall.not employ any person in any amanner - .L. P.0 No, P.
S
o as to become subject to the Workers'Compensation•.Laws. OWNER y- co.Imp.No /"' Poe No.
Dote - I - Applicant ' ADDRE55 �$ �- Q'i ,�/(- e '- TRUNK PERMIT NO �c ROAD PERMIT NO. -
NOTICE:TO APPLICANT: If, after making this Certificate of ' - f a -� AFPIDAVIT WAIVER EASEMENT RfcoaD.INSTR.NO. DATE -
CITY 7
Exemption; you. should -become subject to tfie= Workers' LEGAL - .. .
\ v
Compensation provisions of the Labor code; youmust forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING '
,comply with such provisions:or this permit shall be deemed -
revoked' • - BLOCK TRACT STATE ENCROACHMENT,_NO.OFBLDGS. - PERMIT NO
LICENSED.CONTRACTORS DECLARATION
SIZE OF Lor .NOW ON LOT -1.hereby affirm that-1 am licensed.Under provisions of Chapter USE OF - -- -
9 (commencing with Section 7000) of Oivislon 3 ok the Busi- BUILDINGS - -•^- CHARGES
' nessand Professions Code, and my license Isin full force and -.,'-
effect CONTRACTOR ' CONNECTION CHARGE FEE
License Number LIC.Class ADDRESS - REIMBURSEMENT FEE - Z
Contractor Date - CITY- - TEL NO. DISTRICT NO. "GROUP MAP PROCESSED BY O
- ,
El am exempt under Sec. � of the L.A.Co.. STATE 'UC. _ B� j
LICENSE NO. CLASS d O J
3 .
'
--Plumbing Code and/or Sec. of the NO. DESCRIPTION OFWORK FEE• FINAL s• a'
HOUSE:SEWER CONNECTING TODnTE + ++��// /,�' ' '.VALIDATION to
B 8 P. Code for the fallowing reason PUBUOSEWER, �I z
' •t - - - SEPTIC TANK,'SEEPAGE PIT OR FINAL'
- PITS AND/OR DRA1NF1E1D
- Date " HOUSE'SEWER CONNECTING TO : BY '
- * PRIVATE DISPOSAL SYSTEM '
Signature - - ., _CONNECT ADDITIONAL.BLDG.'OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER. 19Q
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that 1 am exempt from the Contractors License - fir• - ExTN.,CESSPOOL,DRYWELL,MANHOLE ." y
Law for the following reason (Secton 7031.5, Buisness and Pro- .ALTER,REPAIR OR ABANDON HOUSE
11 SCode). SEWER'OR DISPOSAL SYSTEM
hll li i
as owner of the property,'or my employees with wages os
'their-solecompensation, will do the'work and the structureI a`i' YK'ia. s"t ��ti7_ . :.� .{7P_F1
is.not intended or offered for sale (Section 7044,Business. - -
ondProfessions Code).. OWNER'S Permit S BT7 .. -1 T7C,Yui
El 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL'FEE —7 17 !9'fl
licensed contractors tO"C6MWUCt the'project. Section 7044, Tina` 2 .-00'
( _ HAVE AT THIS PATE A CONTRACT WITH THE HEREIW NAMED CONTRACTOR TO _ '1""
-Business and PFOfesSionS Code).. - CONNECT THE ABOVE DESCRIBED EXISTING.DWELLINGjO THE PUBLIC SEWER. t_'�HELY si�I9
CONSTRUCTION LENDING AGENCY _ -SIGNED THIS DAY OF - 19_ 6
I hereby affirm that there is a construction uwh is lending agency �® ctlaNs�E .�la ,.
fora the performance of the work,for which this permit is '. OWNER A
OWNERS AGENT'-
. issued (Sec. 3697, Civ, C:)..' -
Lender's Nome ADDRESS.—
Lender's Address
DDRESSLender'sAddress „ . 6416 _ �1�17r�•4
I certify that I'have read this application and state that the - - '
•above information is correct. I agree to comply with all County .. - _ s, _ _ -
,ordinances and State laws regulating-Plumbing-and'Sewers. - P +,', -and hereby aut ize representatives Of:-this County to enter
-upon the above. ntio d property for inspection pur'p'oses.
q
ignatu of a tee' Dote SEE REVERSE FOR EXPLANATORY LANGUAGE