The URL can be used to link to this page

Home My Public Portal About9177 LAS TUNAS DR_Sewer__ WORKERS'COMPENSATION DECLARATION I heFeby $ffirm that I have a certificate of consent to self insure,•or a certificate of Workers'Compensation Insurance, or 76A642D - a,cervlft�ed'copy thereof Sec 3800, Lab C , 92_�°2 DPW 6,66 APPLICATION FOR PERMIT Policy N4 D O Company?�4_ �f!/�� ❑Certified copy hereby furnished SEWER SEWAGE DISPOSAL , }tel Certified copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY 11 ,Cepartment // Doted Applicant /7 S L— FOR APPLICANT TO FILL IN CONNECTION DATA CER FICATE OF EXEMPTION FROM WORKERS' BUILDING w� COMPENSATION INSURANCE ADDRESS / 7 G x-17 T!/.f/ STATION DEPTH (This section need not be completed If the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less ) LOCALITY LOWER I certify that In the performance of the work for which this ROSS$ST TYPE OF CONNECTION LENGTH FROM V CURB PL ML TOPI permit is issued, I shall not employ any person in any manner , PC No so as to become'sublect to the Workers'Compensation Laws OWNER /L N CO IMP NO JOB NO Date Applicant ADD MAILRE55 \ TRUNK PERMIT NO ROAD PERIhIT NO 1 �� S AFFIDAVITWAIVER EASEMENT RL-,,ORD INSTR NO DATE NOTICE.-TO APPLICANT I_f, after making this Certificate of CITv TEL NO Exemption, you should become subject to the Workers' IEGAL 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 BLDG$ PERMIT NOSIZE OF LOT NOW ON LOT I here-by,offirm that I am licensed under provisions of Chapter y� 9 (commencing with Section 7000) of Division 3 of the Busi- USE O 9 �7 /G ST�`UJ�— CHARGES ness and Professions Code, and my license Is in full force and effect CONTRACTOR L, n�/)� ��/�. , CONNECTION CHARGE FEE License Numberg*!ft.�C '7� Llc Class 4_ ADDRESSQ,3 REIMBURSEMENT FEE Contracto�f DOte I o /h'. ' p r DISTRICT NO GROUP MAP PROCESSED BY 0 _ CIT TEL IC BK PG ❑ I am exem t under Sec of the L A.Co. STATE LIC yJ^ p LICENSE NO CLASS �" Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL pW' HOUSE SEWER CONNECTING TO19/ DATE /'�,,, / VALIDATION (A B & P Code for the following reason PUBLIC SEWER Z SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY /> u 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 �t Law for the following reason (Secton 7031 5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code)- SEWER OR DISPOSAL SYSTEM `�L.,`_•Fo ❑ I,as owner of the property,or my employees with wages as 77 �r�cL.j their sole compensation, will do the work and the structure Is not intended or offered for sale (Section 7044, Business 1 ITEM':: and Professions Code) OWNER'S I Permit $ ❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE (� TOTAL -m I licensed Contractors to Construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOR TO CHECK `:�L r•rJ Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER , 3 -4.50 CONSTRUCTION LENDING AGENCY u [all S�t�E ol.Ii I hereby affirm that there is a construction lending agency SIGNED THIS J SYDAY OF 19 for the performance of the work for which this permit Is OWNER,OR OWNERS AGENT Issued (Sec 3097, Civ C ) ADDRESS Lender's Name Lender's Address X57" i AM st4i 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 jaws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes Signatur�ofPermD SEE REVERSE FOR EXPLANATORY LANGUAGE