HomeMy Public PortalAbout9708 RICHMOND WAY_Sewer__ WORKERS'roAeorkaers'
P SATION DECLARATION 1
I herebyvoffirmfe certificate of consent to self5�Ior p.6erlific6t Coalpensation Insurance.-or 76A662D 1
tetterfo t/ ar f' ec. 38bC.) ` cesoe(REv,aist) APPLICATION FOR PERMIT
�''RCertifi
'Na.���� �impany � � �yr��.�` �s SEWER - SEWAGE DISPOSAL
d copy Is hereby furnished.rtifie 'copy filed with the tc'ornty building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
° depart ent. y�,, ✓
Date/" .' '" < �._._
Applicant_ FOR ICANT-TOFI L IN CONNECTION DATA
CERYfIFICATE OF EXEMPTION FROM WORKERS' BUILD" ; 4 _ STATION ..o- DEPTH
COMPENSATION INSURANCE ADDREhs
(This section need not be completed if the work involved by the '< UPPER
LOCALITY y MANHOLE REFERENCE 3 _r -'-�� (OWER
permit is for one hundred dollars ($100)or less.) NEARESTTYPE OF CONNECTION ` d LENGTH FROM
I certify that in the performance of the work for which this
CROSSST L=" Y. cuReP.L t M.L-TO P.L.
permit is issued, I shall not employ any person in any manner P .No.
so as to become subject to the Workers'Compensation Laws. OWNER CO.IMP,NO. JOB NO
MAILTRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant_ ADDRESS
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR..NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of aTY TEL NO
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. C.— HWY.OR ST WIDENING
comply with such provisions or this permit shall be deemed r-
revoked. .BLOCK TRACT ( STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION I OF BLDGt PERMIT .
SIZE OF LOT NOW ON LOT
I hereby affirm that 1 am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS "- ��✓ CHARGES
ness and Professions Code, and_py license is in full force and
effect. ' 1 :'`' + �, ?, CONNECTION CHARGE FEE
_ Ji CONTRACT n
CL
License NumkSedr, ` Lic.Class_ L ADDRESS REIMBURSEMENT FEE O
COniraCiOr / 'a._3r^&.�...��.. Dfde�"� ���.v-a• DISTRI HO. GROUP_ MAP PRO�jESSEC BY l.1
CITY O. >;}�'� ) 1PG z
/ BK
- .Y 9'
El STATE CLASS I am exempt under Sec. of the L.A.Co, LICENSE NO. CLASS
NO. D R TIO WORK FEE V
Plumbing Code and/or Sec. -of the NAL /' V_ALID ION �
HOUSE SEWER CONNECTING TO DAT
7 PUBLIC SEWER ? ,.
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR
PITS AND,'OR DRAINFIELD B6Y
`
Date HOUSE SEWER CONNECTING TO Y n
PRIVATE DISPOSAL SYSTEM !� rJ '
Signature CONNECT ADDITIONAL BLDG OR ►
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT.DRAINFIELD
I hereby affirm that 1 am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code.): 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). OWNERS Permit JI I, 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 NAMBusiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PCONSTRUCTION LENDING AGENCYI hereby affirm that there is a construction lending agency SIGNED THIS DAY OF �:_
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 Address
I certify that I h Y�' read this application and state that the
above informoti n''is torr I agree to comply with all County
ordinances an State aw regulating Plumbing and Sewers,
and hereby Lyt4Tor' a re resentatives of this County to enter
upon tFye a e-m ratio ed property for inspection purpgges.
;"
l ature of P fpKittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE