HomeMy Public PortalAbout9644 LAS TUNAS DR_Sewer__ WORKERS'COMPENSATION DECLARATION /
I hereby affirm that I have a certificate of consent to self }`
insure, or a certificate of Workers'Compensation Insurance, or 76A642E �J
a certified copy thereof (Sec. 3800, Lab C.) �E 809 u APPLICATION FOR PERMIT
Policy No.� Uf- .f"Company5t !+' `.
❑ 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.
Dote Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING ,. STATION DEPTH
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the MANHOLE REFERENCE r e � UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY 1 I C- r
NEAREST > -. TYPE OF CONNECTION LENGTH FROM
(
I certify that in the performance of the work for which this CROSS ST. 'it < Y. CURB P,I. M,L,TOP.I.
permit is issued, I shall not employ any person in any manner P.C.NO,
so as to become subject to the Workers'Compensation Laws. OWNER 4 - CO.IMP.NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date. Applicant ADDRESS It g
NOTICE TO APPLICANT: If, after makingthis Certificate e
cae oAFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CITY S�C I �/k/, TEL.NO. C,. - M1 t.A.. :. ._
Exemption, you should become subject to the Workers' LEGAL 1
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 „l/ 7 j
LICENSED CONTRACTORS DECLARATION NO.of LOT PERMIT o. (F
SIZE OF LOT NOW ON LOT `/
I hereby affirm that I am licensed under provisions of Chapter USE OF Z- ' > r
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and /
effect. CONTRACTOR hi w .1 CONNECTION CHARGE FEE
7 ��L'.1 /. Lic.Class 1' a Ct `%. REIMBURSEMENT FEE
License Num//ber��„F. ADDRESS 1 f.. a }
Contractor s ft.a G>.;-<<`-» :�ate CITY - .- .; , TEL.NO. I C �j � c- = DISTRICT NO. GROUP MAP PR ESSED BY a
BK PG
COntrV
❑ 1 am exempt under Sec. of the L.A.Co.
STATE
NO _Y'', ciA s
e and/or Sec. of the NO. DESCRIPTION Of WORK FEE FINAL r O
ks
Plumbing Cod HOUSE SEWER CONNECTING TO DATE / VALIDATION u
B. R P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR FINCI.
PITS AND/OR DRAINFIELD BY / h
rJ Date HOUSE SEWER CONNECTING TO BY !� Z
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
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
heir 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 $
F-1 I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project (Section 7044, I 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 DAY OF 19OR _
for the performance of the work for which this permit is OWNER
OWNERS AGENT
issued (Sec. 3097, Civ. C.}.
ADDRESS
Lender's Name ," t
Lender's Address
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 laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
Upon the above-mentioned property for inspection purposes.
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%�"=ature of Perm itee Date SEE REVERSE FOR EXPLANATORY LANGUAGE