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HomeMy Public PortalAbout9459-9473 LAS TUNAS DR_Sewer__ _ WORKERS'COMPENSATION DECLARATION ~hOeb,t offirzn that I have a certificate of consent to self 'i , ,nsureor a certificate of Workers'Compensation Insuranceor 76A642D a certified copy thereof(Sec. 3800, Lab C. CE 808(REV,B/B,, APPLICATION FOR PERMIT Policy No. Company ©s ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA . CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS t ✓ y� 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 NEAREST / TYPE OF CONNECTION LENGTH FROM _ I certify that in the performance of the ork for which this cRoss sT. � U��'�' Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ an rson ' any manner P.C.NO. so as To become subject to the Wo Comp n atlon 5. OWNER Z CO.IMP.NO. JOB NO. �f A� MAIL C TRUNK PERMIT NO. ROAD PERMIT NO. Do a/ �a/Applicant U/� ADDRESS Q� NOTIC TO APPLICANT: If, a Ter king Cer11fic to of +', Cn1'_ � _pry AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE g CITY W�V w TEL:NO. Q� QV'V Exemption, you should become sabje 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. y PERMIT NO. SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the BUST- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE } License Number Lic.Class ADDRESS ✓ REIMBURSEMENT FEE Contractor Date `.�yf DISTRICT NO. GR UP MAP PR ESSED BY V CITY EL.N ,/ / / r`{/ BK PG Z ❑ I am exempt under Sec. of th'e L.A.Co. Srnre �y LIC. .J\//C U b 1, .1 Q p LICENSE NO, L 9 CLASS �(,j� Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE V FINAL W HOUSE SEWER CONNECTING TO hB n PUBLIC SEWER B. 8 P. Code for the following reason � CJ � VALIDATI Z SEPTIC TANK,SEEPAGE PIT OR NA ' PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE Z /� Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 2 /r7 4 3,9 n fessions Code): SEWER OR DISPOSAL SYSTEM H •,• • •11 0 ❑ 1,as owner of the property,or my employees with wages as 4 - 27.50 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business • • 2 7 5 0.50 and Professions Code). OWNER'S I Permit $ J s o7,09.+87 El1,as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE licensed Contractors to construct the project (Section 7044, 1 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. CONSTRUCTION LENDING AGENCY ©© , I hereby affirm that there is a construction lending agency SIGNED THIS Y OF 190 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 I certify that I have read this application and state that the above informatio is correct. I agree to comply with all County ordinances ate law regulating Plumbing and Sewers, and hereb horize r r sentatives f this County to enter upon t ove-menti d proper or ' spectiop purposes. d Signature of Pe a Dare SEE REVERSE FOR EXPLANATORY LANGUAGE