HomeMy Public PortalAbout9139 LAS TUNAS DR_Sewer__ -*ORKERS' COMPENSATION DECLARATION
' re 'y"f;affirm that I have a certificate of consent to self
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lrirvre, oVa ccvraificate of Workers'Compensation Insurance, or,
• P�Iey�NTnZy6 �T`� �8;Ry ' Its, Ac,�rcy COPESBDB(REV.B,B,) APPLICATION FOR PERMIT
Czrtified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with The county building inspe ion COUNTY OF LOS ANGELES BUILDING-AND.SAFETY
department.
Date �t""Z Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING -� STATION DEPTH
COMPENSATION INSURANCE ADDRE55 /-AS I f,) 6 Z f JQ r U
(This section need not be completed if the work involved by theLOCALITY ` MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOWER
NEAREST TYPE OF CONNE LENGTH FROM
1 certify that in the performance of. the work for which this CROSS ST. Y. RB P.I. , M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. OWNER E + 6A/57i CO.IMP,NO. [ Z JOB NNO.
Date Applicant
MAIL *� = TRUNK PERMIT NO. ROAD PERMIT NO.
ADORE55.� 6 � � /`
This Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making CITY TEL.NO. �-b7
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 ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PER T No.
SIZE OF LOT NOW ON LOT' rn_ 2 �•
I hereby affirm that I am licensed under provisions of Chapter USE OF 3 /
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHAR E5
ness and Professions Code, and my license is in full force and
effect. n CONTRACTOR L C.'�, CONNECTION CHARGE FEE
License Number. Q'I,SU LIC./{CIOSS C�C 3Q� ADDRESS ;33 �E�,� ` CL
REIMBURSEMENT FEE O
Contractor :1� 'l PQb F� te J.' �� 1 CITY �u� fC/T�-{T TEL.NO. L,,,j DISTRICT NO. GROUP MAP PROCESSED BY V
�1 BK PG Z
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO.�&30 . 0 ciASs 0
NO. DESCRIPTION OF WORK FEE ` '�
Plumbing Code and/or Sec. of the FINAL VALIDATION d
HOUSE SEWER CONNECTING TO DATE
B. & P. Code for the following reason PUBLIC SEWER / N
_ SEPTIC TANK,SEEPAGE PIT OR !/
PITS AND/OR DRAINFIELD FINAL
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
fessions Code): - SEWER OR DISPOSAL SYSTEM -
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structurel_
is not intended or offered for sale (Section.7044, Business _ _ ._•
and Professions Code). OWNER'S Permit $
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE , o .! 'a $—
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 DESCR ED EXISTING DWELLING TO THE PUBLIC SEWER. '•='-" _ `
Ai
CONSTRUCTION LENDING AGENCY /�/°'''
SIGNED.THIS"L+& DAY OF �%.�I..8C� '.J
I hereby affirm that there is a construction lending agency 19-� , i"'i�'t'ui� � -=
for the performance of the work for, which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT
ADDRESS
Lender's Name
Lender's Addres;3?6 3� JgA
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 laws regulating Plumbing and Sewers,
and hereby authorize representati es of this County to enter
upon ab�Ge-me lone p for inspection purposes.
wQ
Signatur of Permittee—V Date, SEE REVERSE FOR EXPLANATORY LANGUAGE