HomeMy Public PortalAbout9511 LAS TUNAS DR_Sewer__ WORKERS' COMPENSATION'b
I hereby, --that I have a certificate of o self
insure,`!r a certificate'df Workers'Compensation .rti once, Or 76A642D .
a certified�tereofSec. 3800, Lab C.) CE808(REV.8/81) APPLICATION FOR PERMIT
Policy Nompany r ^ � esCertifiby furnished. SEWER . SEWAGE DISPOSAL
Certified copy is filed with the county building.inspection �- COUNTY OF LOS ANGELES BUILDING AND SAFETY
dep tme t.
DoteC�Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CER IFICATE OF. EXEMPTION FROM WORKERS' BUILDINGl S STATION Z3 DEPTH
COMPENSATION INSURANCE ADDREss v i
(This section need not be completed if the work involved by the �/� �" MANHOLE REFERENCE �j / LIPPE
permit is for one hundred dollars ($100)or less.) LOCALITY t l l_/� 1 114q LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. CURB L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner 0.
so as to become subject to the Workers'Compensation LOWS. OWNER t P.C.NO.
e CO.IMP.NO. - 1 `. JOB NO. 0
MAIL w f TRUNK PERMIT NO. ROAD PERMIT NO. cc
Date Applicant ADDRESS ^r �V _
NOTICE TO APPLICANT: If, after making this Certificate of CITTEL.NO �I►s,� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
Y � . //
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING t0.
comply
with such provisions or this permit shall be deemed t�
revoked. BLOCK TRACT STATE ENCROACHMENT _
`m
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT
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 Busi- BUILDINGS llJ CHARGES
ness and Professions Code, and my license is in full force and
effect. - CONTRACTOR F ` CONNECTION CHARGE FEE'
License Number Lic.Class ADDRESS S REIMBURSEMENT FEE
a.� FW1
• 2 T� DISTRICT NO. GROUP MAP PRO SSED BY
Contractor ate — [ CITY 64 s TEL.NO. sill;--3 �I'�
.. STATE LIC "BK PG
❑ 1 om exempt under Sec. of the L.A.Co. LICENSE NO. CLAss /�V
�^ G 151
Plumbing Code and/or Sec. of the NO. -DESCRIPTION OF WORK FEE' FINAL
HOUSE SEWER CONNECTING TO //'tfj DATE ,_. VALIDA ION
B. & P. Code for the following'reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR
- PITS AND/OR DRAINFIELD FINALBY /�
Date HOUSE SEWER CONNECTING TO
- PRIVATE DISPOSAL SYSTEM
SignaturL- 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 -
❑ 6 U 9 A
I,as owner of the property,or my employees with wages as
their solecompensation, will do the work and the structure # 0 0 0 0 .1 0
is not intended or offered for sale (Section 7044, Business •
and Professions Code). OWNERS Permit $ L Q ( o o 2 7,5 0
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION-1—TOTAL FEE o o ®
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATEIA CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 2 7'5 O_U
Business and Professions Code). CONNECT THE ABOVE DESCRIBED.EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY =" `„r rim- 0 9.09-85
D THIS+ DAY OF 19_
I hereby affirm that there is a construction lending agency SIGNE ..
for the performance.of the work for which this permit is OWNER
issued (Sec. 3097, Civ. C.).
OWNERS AGENT
ADDRESS
Lender's Name
Lender's Address
I certify that.l 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 authirlte representatives of this County to enter
upon thebov e tion operty for inspection purposes..
Q fes}
Cign ure of Per, '1 Date SEE REVERSE FOR EXPLANATORY LANGUAGE