HomeMy Public PortalAbout9714 RICHMOND WAY_Sewer__ WORVRS'COMPENSATION DECLARATION
I hereO affirm that I have a certificate of consent to self
insure .jr a certificate of Workers'Compo*satlon Insurance, or � 76A642D
fN6.
� prr/ E.ereyfp'( cpan9 _' "�
L - -{ � � 081REV9,81, APPLICATION FOR PERMIT
ie, r -
ertified copy,is hereby furnished. SEWER - SEWAGE DISPOSAL
L I Certif 'd co is filed with the apuniy building in coon COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Iep t ent
Dater` Applicant l t � �� y`� FOR PLICANTTCf*ILL IN CONNECTION DATA
CE IFICATE OF EXEMPTION FROM WORKERS' BUILD IN r 31 61 COMPENSATION INSURANCE ADDRES ",.: ", STATION DEPTH
This section need not be completed if the work involved b the UPPER
permit is for one hundred dollars ($lOO)Or less.) y LOCALITY MANHOLE REFERENCE b R
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. w i Y. CURB P.L. M.L TO P.L,
permit is issued, I shall not employ any person in any manner x F: PC NO.
so as to become subject to the Workers'Compensation Laws. OWNER - F _-- �ttll , CO.IMP.NO. JOB NO.
Date Applicant ADDRESS
ry'MAIL TRUNK PERMIT NO ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after makingthis Certificate of _�r AFFIDAVIT WAIVER EASEMENT RECORD.INSTR_NO. DATE
CITY Y TEL.N.O. ?"'-G
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 .
revoked. BLOCK TRACT 4 STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION 140 OF BL GS. PERMIT NO.
SIZE OF LOT NOW ON LOT y` $ p,
I hereby affirm that I am licensed under provisions of Chapter USE OF ''"3 �d"aS, f�.J I, ./
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. " CONTRALTO F, ; �.%:,._ ,. ,�-' CONNECTION CHARGE FEE �.
License Nlrhtlbe' LiC Class/i'> ADDRESS - REIMBURSEMENT FEE
,c' ♦'`7 -- 7 DISTRICT NO GROUP MAP PRO�ESSED BY V
Conirac'r` �. J l Date CITY TEL.NO. f K PG F Z
STATE <� �..�' LIC. C r�. C f��.. �y �
El am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS �° PP w° 1
Plumbing Code and/or Sec. of the NO D 5C IPTI N OF WORK FEE FINAL W..
HOUSE SEWER CONNECTING TO DATE Z,;-1 . VALID ION a..
B. & P. Code for the following reason PUBLIC SEWER 41
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD PI
Y
Dote HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
f c_
OVERFLOW SEEPAGE PIT,DRAINFIELD oilO
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOLer,DRYWELL,MANHOLE 6 ; in
Law for the following reason (Secton 7031.5, Busness and Pro- ALTER,REPAIR OR ABANDON HOUSE 7" •�'it; s
fessions Code): SEWER OR DISPOSAL SYSTEM (t a sr 0 0 ;}
❑ 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 $
Permit
and Professions Code). OWNER'S _
❑ 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 TU
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
OWNERS AGENT
issued (Sec. 3097, Civ. C.).
ADDRESS
Lender's Name '
Lender's Address
I certify thahave re is application and state that the
above inf�0jrt'uthor&ze
ation is"
s orrect I agree to comply with all County
ordinanced Stcyfe law regulating Plumbing and Sewers,
and her re resentatives of this County to enter
upon.rh✓�ibove-m4ntioo..de pXbperty for inspection purpas�. �
i natu re of'P tee Date SEE REVERSE FOR EXPLANATORY LANGUAGE