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HomeMy Public PortalAbout9112-9114 LAS TUNAS DR_Sewer__ 4�WORKFeS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance; or ieAaa2D Rrtified cop thereof,(Sec. 3800, Lab C.) CE 808(REV.B/Bl) p pang , �/ � ©s APPLICATION. FOR PERMIT fied copy is hereby furnished. SEWER - SEWAGE DISPOSAL ; Certified copy is filed with the county building inspection -COUNTY OF LOS ANGELES BUILDING AND SAFETY " c epartment. Dcd® gsplicaC/ FOR APPLICA T TO FILL IN CONNECTION DATA CERTIFICATE•OF.EXEMPTION FROM RKERS' BUILDING srnnoN �7 DEPTH COMPENSATION INSURANCE ADDRESS . G`;' r / r (This section need not be completed if the work involved by the. LOCALITY RENCEa��j/o33 ISi �? I• 0 6T UPPEER MANHOLE REFE permit is for one hundred dollars ($100)or less.) FO NEAREST �'- TYPE OF CONNECTION LENGTH FROM 91 I certify that in the performanceofthe work for-which this CROSS ST. Y. CURB P 1 M.L.TO P.L.- permt- it is issued, I shall not-employ" person in any manner bbject.to the Workers'Compensation Laws. NO. . so as to become su � _ P •� OWNER�� �(/ CO.IMP.NO. JOB JOB NO.' MAIL TRUNK PERMIT NO. . ROAD PERMIT NO. - Date Applicant ADDRESS NOTICE TO APPLICANT: If, after making this.Certificate of CITY 't7 i AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE Exemption; you should become subject to the Workers' LEGAL Compensation provisions of the Labor code; you must forthwith DESCRIPTION LOT NO. - HWY.OR ST.WIDENING comply with,such provisions or this permit shall be deemed revoked.- - - BLOCK TRACT STATE PERMIT NO.ENCROACHMENT- LICENSED CONTRACTORS DECLARATION NO.OF BLDCS. SIZE OF LOT NOW ON LOT - - - 1 hereby offirm,that I am licensed under provisions of Chapter, USE of 9 (commencing with Section 7000) of Division 3 of the BUsI' BUILDINGS CHARGES riess and Professions Code, and my license is in-full,force and effect. `y/ CONTRACTOR CONNECTION CHARGE FEE IL License Nne ic.Class, C yr��y� ADDRE MBURSEMENT FEE 0- U 111 �TEtr. ., BK P DISTRICT NO. GROUP MAP PROCE SED BY _ V S S .D Z STATE LIC. O El am ex pt under Sec. of the L.A.Co.. LICENSE No. � CLASS �~ L 1 t`. Plumbing Code and/or Seca of the NO. DE$G IPTION.OF WO FEE FINAL - - V HOUSE SEWER CONNECTING TO - I �� DATE, VALIDATION y B: & P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR - Z- - - PITS AND/OR DRAINFIELD FINAL r Date- - : HOUSE SEWER CONNECTING TO BY - - PRIVATE DISPOSAL SYSTEM - Signature - CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton.7031.5,BUisness and Pro- -ALTER,REPAIR OR ABANDON HOUSE fesslons Code: - '- SEWER OR DISPOSAL SYSTEM t ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044,,Business. Permit $ U 4 8 4 6 A and Professions Code). OWNER'S J . I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE #'e ®I• • licensed Contractors to construct the project (Section 7044, I HAVE AT THIS.DATE A CONTRACT-WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code): CONNECT THE'ABOVE-DESCRIBED EXISTING-DWELLING TO THE PUBLIC SEWER.; ' • •,2 X71 5 O CONSTRUCTION LENDING AGENCY SIGNED THIS DAY OF 19_ 2 I hereby affirm that there is a construction lending agency e •.* 27.5 Q,5 for the performance of the work for which this permit is OWNER OR - OWNERS AGENT ' issued (Sec. 3097, Civ. C.). '06. 19:_t86 - - ADDRESS 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 o,dina es State laws regulating Plumbing and Sewers, an e y out orize representatives of this Cou ty nter ori the abov -mentioned pro, Inspecti urposes. Signoture of Per ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE /`