HomeMy Public PortalAbout9674 LAS TUNAS DR_Sewer__ • i'4'(7RkERS'CObIPENSATION DECLARATION CE 808 D A P P L I C AT I N FOR PERMIT
I 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,Lab,C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
FOR APPLICANT TO FILL IN CONNECTION DATA
D Certified copy is hereby furnished. _
BUILDING STATION s�"•.��f^' 7 ` DEPTH
Certified copy is filed with the county building inspection ADDRESS f
department, MANHOLE REFERENCE �jc R
Maw
LOCALITY // r LOWER
DatC Applicant NEAREST TYPE OF CONNECTIQAi"`t-Q LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. V _ Y. CURB P.L.i M.L. TO P,L.
COMPENSATION INSURANCEl/�+ P.C. NO.
OWNER ,;Bl P�^�iiesr CO. IMP, NO. JOB NO.
MAIL
(This section heed not. be completed If the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. >_
by the permit is for one hundred dollars (5100) or less.) APh IOAVIT WAIVER EASEMENT REL'ORD. INSTR.NO. DATE 0
CITY TEL. NO. 0
I certify that in the performance of the stork for which this LEGAL
permit Is issued, I .shall not employ any person in any manner DESCRIPTION LOT NO. , HWY. OR 57. WIDENING
so as to become subject to the Workers' Compensation Laws.
BLOCK TRACT STATE ENCROACHMENT
PERMIT NO,
! Datgo�2/ Applicant " e � � NO. OF SLOGS. LU
NOTICE TO APPLICANT: If, aftfr making this Certificate of sizE of LOT NOW ON LOT LL
Exemption, you should become subject to the Workers' USE OFI CHARGES
Compensation provisions of the Labor Code, you must forth-
BUILDINGS
with comply with such CONNECTION CHARGE FEE
p y provisions or this permit shall be CONTRACTOR �4".4� * � �' ��_� .�
deemed revoked.
REIMBURSEMENT FEE
yy t, LICENSED CONTRACTORS DELI ARAATION ADOREssb?',,rf��.
`i hetcby affirm that I am licensed under provisions of Chapter 4 DISTRICT NO. GROUP ®K MAP PO PROD E„SSED BY
CITY' � TEL. NO. -. .-" �)
9 (commencing with Section 7000;) of Division 3 of the Busi- '° "_ / l
ness acid Professions Code, and my license is in full force and STATE � � LI C. "� C �adi
effect. LICENSE NO. CLASS `a +:
NO. DES RIP 10 OF WORK FEE FINAL VALIDATION
K HOUSE SEWER CONNECTING TO
Li ense N crib r Li,.Class .Je PUBLIC SEWER MATE
SEPT'iC TANKa IMEPAGE PIT OR _
�� - ,- PITS E SEW CO NF CTI
Contractor Date � — - FINAL
HOUSE SEWER CONNC-CTING TO
PRIVATDISPOSAL SYSTEM
® -__ �`'
E.
I am exempt from the licensing requirements as I am a
CONNECT ADOiTtO NAL6LD0.OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting in my professional capacity (Section '7051, Bus- OVERFc.OW SEEPAGE PIT,DRAINPIELo
iness and Professions Code). EXTN.,CESSPOOL, ORYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic.or Reg.No.__ Date-
HOME OWNER-BUILDER DECLARATION _
I hereby affirm that I am exempt from the Contractor's OWNER'S Permit S
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATIONI TOTAL FEE
ness and Professions Cade):
1 HAVE❑ AT THIS A CONTRACT. WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
1, a5 owner of the property, will do ttie work and the TO THE PUBLIC SEWER.
structure is not intended or offered for sale (Section SIGNED THIS SAY of is
7044, Business and Professions Code). OWNEROR
OWNERS AGENT
CONSTRUCTION LENDING AGENCY ADDRESS
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.).
Lender's Name _
Lender's Address
-
I certify that I have read this application and state that the
above information is eonec;t.I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to entei
upon the above-rnentioncd property for inspection purposes-
SEE REVERSE FOR EXPLANATORY LANGUAGE
a
A- Sature of Terinittee Date