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HomeMy Public PortalAbout9663-9665 LAS TUNAS DR_Sewer__ WORKERS'COMPEN-ATIOts! CCLARATION I h oy oftirm that I have %u certificate of consent to self iv.sure, orb certificate of Workers'Compensation Insurance, or a464zo e a cC., A 8°8 iREV 1 N` APPLICATION FOR PERMIT Policy No.______.'"ompany ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL INI,I�I 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' C' COMPENSATION INSURANCE ADDRESS w, STATION e DEPTH (This section need not be completed if the work involved by the LO 7C MANHOLE REFERENCE,y r f,) v S DPpR permit is for one hundred dollars ($100)or less,) I certify that in the performance of the work for which this CROSS ST, Y TYPE OF CONNECTION y^^_i, LENGTH FROM CURB / P.L.'�"' M.I.TO P.L. permit is issued, I shall not p o any perso in any manner r so as to become subject to he Wor ers' Co ensotion Laws. OWNER j „ /' (, CO.IMP_NO. JOB NO YorLatehios MAIL ;_ " � Z - TRUNK PERMIT NO. ROAD PERMIT NO. Date -�� pplica . --L.wi ADDRESS '* jNOTICE TO APPLICANT: Itmaking this Certificate Of CITY s X '! AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO DATE Exemption, you should subject to the Workers � �� L.No. �,© 1rCom ensotion rovisions orcode, ou must forthwith EGALp py DESCRIPTION LOT NO. HWY OR ST.WIDENING comply with such provisio permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION No of BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT �,�'//�,� I hereby affirm that I am licensed under provisions of Chapter USE of Taul. 3+>�� 9 (commencing with Section 7000) of Division 3 of the Busi- BuaolNGs c':''-`tt �= CHARGES ness and Professions Code, and my license is in full force and f effect. ) CONTRACTOR �r_ �7 ?mss` CONNECTION CHARGE FEE License Number LiC.Class 3(( ADDRESS S /f�l �„y?- REIMBURSEMENT FEE a Contractor Dote w D FSx ' CITY J 4I r TEL NO. �' � DISTRICT NO GROUP MAP PjtOC SED BY U /� J ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO [.' CLASS /1/ � ; /y�� 0 O H Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL VALIDATI N W 'HOUSE SEWER CONNECTING 70 DATE PUBLIC SEWER B. & P. Cod the following.reason l �� o- �, SEPTIC TANK,SEEPAGE PIT OR � H PITS AND/OR DRAINFIELD FIN Z Date HOUSE SEWER CONNECTING TO B ` /� �. R BL.1 PRIVATE DISPOSAL SYSTEM Inz"-Li'h+c__ Signature CONNECT ADDITIONAL BLDG OR , ILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby offir at I am exempt from the Contractor's License EXTN.,CESSPOOL DRYWELL,MANHOLE Law for the f wing reason (SeCtOn 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Co 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 V is not intended or offered for sale (Section 7044, Business P and Professions Code). OWNERS Permit S } 43 d t) S p . ❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION FTOTAL FEE17 7 1_57C . e e • r 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. ! • e r} , `:i CONSTRUCTION LENDING AGENCY - 1, 5 , 1 hereby affirm that there is a construction lending agency SIGNED THIS-DAYr'OF 19 _5 • e r 2 i7,5 Q v for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT 0 ADDRESS `i 4,0 33Lender's Name 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 ordinance,S rld State laws regulating Plumbing and Sewers, and hipwzy au orize repre ntatives of this County to enter upon'1he abo tione roperty for inspection purpos ', t 1 Sk na re f Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE