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HomeMy Public PortalAbout9707 RICHMOND WAY_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self e, or q er ificote of Workers'C nsation Insurance ®r 7eAta2D ° icer if �apy. ege. 'IeG 38 b CE 808(REV 8%81j APPLICATION FOR PERMIT �olicy. �' � Cbmpany `� "i ... U l �.� ©s X,ertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL rtifie copy is filed with e county buildin in pection COUNTY OF LOS ANGELES BUILDING AND SAFETY deport ent. �, Daterrj77`'�d f Applica r 'ti— ' - FOR APPLICANfT FILL/N CONNECTION DATA CE_ IFICAT'E OF EXEMPTION FROM WORKERS' BUILDING 1 COMPENSATION INSURANCE ADDRESS �t sranoN DEPTH �... (This section need not be completed if the work involved by the �, / MANHOLE REFERENCE ^j, _ UPPE 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 work for which This CROs sr, "�-��'t..t-�-� Y. cuRe P.L�^� 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'Compensation Laws. pprr P.C.NO. OWNER . f .. ..-G, CO.IMP.NO. JOB NO. MAIL '" TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS �- y NOTICE TO APPLICANT: If, after makin this Certificate of �/ a AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO DATE g CITY TEL.NO. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the labor code, you must forthwith DESCRIPTION LOT No. ..y comply with such provisions or this permit shall be deemed HWY.OR 51.WIDENING revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.O BLDGS. PER T No. y� I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT -3 -L!uSE of ) t 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGSCHARGES CONTRACTOR � ness and Professions Code, and my..kicense is in full force and ,p effect. } r CONNECTION CHARGE FEE y License Number Lic.Class ADDRESS REIMBURSEMENT FEE O JAY R ' `4Datef f ' a'� CITY - NO DISTRICT GRGU MAP PROCESSED BY V Contra'for 4�ie" d STATE ..-;- ..'. UC, ,¢ t.,..� 1K p PG 0 ❑ 1 am exempt under Sec. of the L.A.Co. uCENSE LIC . ES RIPTION WORK Plumbing Code and/or Sec. of the NOFEE FINAL q W HOUSE SEWER CONNECTING TO tl DAT VALIDA ON o. �; S B. & P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR d Z PITS AND/OR DRAINFIELD FINAL_,„ Date HOUSE SEWER CONNECTING 1'0 BY 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,DRYWEU,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE i� fessions Code): SEWER OR DISPOSAL SYSTEM - ❑ I,as owner of the property, or my employees with wages as fOf their sole compensation, wilt do the work and the structure is not intended or offered for sale (Section 7044, Business F u; and Professions Code). OWNERS Permit $ (/ ❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION 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 DAY OF 19 for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS Lender's Name Lender's Addre Tom} I certify that av this application and state that the above infor a o Is co rect. I agree to comply with all County ordinance a d State ows regulating Plumbing and Sewers, and here y ulhoriz representatives of this County to enter upon fife ove,.me 'tioned property for inspeCtion?urposes. ioz- / Pnature 0 ermittee lbate SEE REVERSE FOR EXPLANATORY LANGUAGE