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HomeMy Public PortalAbout9510 LAS TUNAS DR_Sewer__ WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure,pr a certificate of Workers'Compensation Insurance, or 76A6A2D a certified copy thereof (Sec, 3800, Lab C. CE 808(REV.8/81) APPLICATION FOR PERMIT Poli No. -. Company ©s 1 Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certifie copy s filed with the c my buil inspe ion COUNTY OF LOS ANGELES BUILDING ANDISAFETY de�par000, X; Date Appy FOR APPLICANT T IL CONNECTION DATA CE IFICATE OF EXEMPTION'FROM WORKERS' BUILDING STATIONDEPTH COMPENSATION INSURANCE ADDRESS (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 L NGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. CURB 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 Com ensation Laws. P.c.No. I p OWNER CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDREs NOTICE TO APPLICANT: If, after making this Certificate of CITY O AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE Exemption, .you should become subject to the Workers' LEG Compensation provisions of the Labor code; you must forthwith DESCRIPTION LOT NO. d — 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. PERMIT NO. SIZE OF LOT NOW ON LOT. F Hereby affirm that I am licensed under provisions of Chapter USE OF (�J 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS, CHARGES ness and Professions Code, and my license is full force and _ --eff�t ...Q .. .b� � CONTRACTOR CONNECTION CHARGE FEE License Nu mfr�e r`1J (r Li IaSs / I REIMBURSEMENT FEE 01 L ADDRESS Contra aCITY DISTRICT NO, GROUP MAP PROCESSED BY � Q' EL. BK PGO El am exempt under Sec. of,the L.A. a. LICENSTATE No.• �"� Llc 5`�— "r% U� L` y3 " F —CL Plumbing Code and/or Sec. of the NO. DESCRIPTIOOF WORK FEE - _ V FINAL VALIDATION HOUSE SEWEN R CONNECTING PUBLIC SEWER TO DATE -�� B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGEE N OR FIN z PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM �7 f 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 Cade): 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 structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER'S Permit $ 0 ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 2.7 3 5 7 A licensed contractors to construct the project.(Section 7044, 1 HAVE AT THIS DATE A.CONTRACTWITH THE HEREIN A ED ONTRACTOR TO, }}yy Business and Professions Code). CONNECT.THE ABOVE DESCRIBED EXISTI D LING TO E C SEWER. tt'e�p •I•;J O CONSTRUCTION LENDING AGENCY �/�f e' R+I'hereby affirm that there is a construction lending agency SIGNED THIS DA 19_ 5 0 for the performance of the work for which this permit- ispwNEiSOAGEN_T Q , e.o 0 22'� 0IP issued (Sec. 3097, Civ. C.). �� Lt.A Lender's Name ADDRESS 0629487 Lender's Address Icertify that I have read this application and state that the above ' formation is correct. I agree comply with all County ordi ces and laws regul mg.Plumbing'an'd Sewer , a ereby auth A res atives of this C my to e he above roperty for pec t'o�os, • Signature of Permittee to SEE REVERSE FOR EXPLANATORY LANGUAGE