HomeMy Public PortalAbout9711 RICHMOND WAY_Sewer__ WORKERS' COMPENSATION DECLARATION
here�j+ylr of firm," t at I d Eve a certificate of consent to self
ocerti(fkAe �Workers'Cgnapqpnsation Insurcm e.,or 76A642D
cQftife op Tr S+# Sec. 3B0 ab C.# CEBDB,REV.B,3,, APPLICATION FOR PERMIT
Policy No. � ompany I=Ly4 ls[ ,IJs
Certifi, d copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified:copy is filed with tom,county buildin jnspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depart ent. t
DatgF Applicantf 'vZ_ '- " i'"j FOR APPL TO FILL IN CONNECTION DATA
CE IFICATE OF EXEMPTION FROM WORKERS' BUILDING STATIONt 1 DEPTH
COMPENSATION INSURANCE ADDRESS 4' [„!: f 7
(This section need not be completed if the work involved by the ; UPPE
permit is for one hundred dollars ($100)or less.) LOCALITY MANHOLE REFERENCE � .�i ( 1 ER
NEAREST TYPE OF CONNECTION �� LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. - Y. CURB P L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner P.C.NO.
so as to become subject to the Workers'Compensation Laws. OWNER CO.IMP,NO. .LOB NO.
MAIL. -""` TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant _ ADDRESS `y
this Certificate of {r,, AFFIDAVIT WAIVER EASEMENT RECORD.IN$TR.NO DATE
NOTICE TO APPLICANT: If, after making CITY �i��Iav 7EL.NO. !"`�,;�,r✓-
Exemption, you should become subject to the Workers' LEGAL
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 r p-
revoked. BLOCK TRACT - ; STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT OF BLDGS. PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter USE OF Y
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS 1"!„ CHARGES
ness and Professions Code and'tay'license is in full force and
effect. + ' CONTRACT14 +- �' CONNECTION CHARGE FEE }
11L
License N �ritper Lic.Class_ ADDRESS REIMBURSEMENT FEE O
Contract-Or4 ii. Date �rT L DISTRICT NO. GRO P MAP PR SSED BY u
CITY TEL.NO� �,,/, yi C,. ' ,BK PG } Z
El am exempt under Sec. of the L.A.Co. STATE �` CL 6 a O
p LICENSE NO. � -- CLASS � x. 4 PC' '�`�• ,,{{{CCC
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF ORK FEE UFiNAt VALIDA ON d
HOUSE SEWER CONNECTING TO y' � DATE _.--� y
Z
B. & P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR FINA
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO B „ K
PRIVATE DISPOSAL SYSTEM ♦ `'
Signature CONNECT ADDITIONAL BLDG.OR ► /'f"//
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License EXTN.,CCESSPOOL DRYW LL,DRAMANHOLE
Law for the following reason (Secton 7031.5, BDisness 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). OWNER'S Permit $ q �
❑ 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 NAMED CONTRACTOR TO
Business and Professions Cade). 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 Address
1 certify that I ' ve read his application and state that the
above in ma n is coI agree to comply with all County
ordinances a Stat s regulating Plumbing and Sewers,
and her uthor' a epresentatives of this County to enter
upon the a ave- n ned property for inspection rpose .
ure of emittee Date,.--
ate SEE REVERSE FOR EXPLANATORY LANGUAGE
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