HomeMy Public PortalAbout9715 RICHMOND WAY_Sewer__ f
WORK S'COMPENSATION DECLARATION
I herebw.affirm.' I;WA}'have a certificate of consent to self
. , r or&cyfiifj,SO4 "dt Workers' pen_sation Insurance, or 76A642D
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PolicNo. coPympan8, � Al
508tREV B B„ APPLICATION FOR PERMIT
certifi copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified opy i filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deoia!tm t., :11 ° t
Date tiro /' `%pplicanty +� FOR APPLIC 'FILL IN CONNECTION DATA
CERTI KATE OF EXEMPTION FROM WORKERS' PI-A
_ .- F STATION DEPTH
COMPENSATION INSURANCE
(This section need not be completed if the work involved by the 'a. MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) s LOWER
I certify that in the performance Of the work for Which this `� TYPE OF CONNECTION LENGTH FROM
y P ¢ :�" Y. CURB P L. M.L TO P.L.
permit is issued, I shall not employ any person in any mannerso as to become subject to the Workers'Compensation Laws. r :�yco IMP.No. Poa No.
TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant g„ , — ,,NOTICE TO APPLICANT: If, after making this Certificate Of J yam{ ' a AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO. DATE
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Exemption, you should become subject to the Workers' LEGAL `` TEL.No. ' c'
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 4
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 f
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS r CHARGES
ness and Professions Code, and my license is in,,full force and
effect _ f- yJ^/y7 CONTRACTOR � 1 CONNECTION CHARGE FEE
License Numb Er • � Lic.Class_ s, ADDRESS - {� r REIMBURSEMENT FEE O
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'°j, Fe• __w ;+� y- DISTRICT N0. GROUP MAP PROCESSED BY V
Contra ��.! Date 6� � CITY TEL
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STATE ✓® UC.
ElI am exempt under Sec. of the L.A.Co. UCENS€NO. CLASS i "x O
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Plumbing Code and/or Sec.— of the NO,, DESCRIPTI(DN OF WORK FEE U FINAL VALIDATION it
HOUSC SEWER SEWER CONNECTING TO �`7 ? � DATE � dl),�.�.
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B. & P. Code for the following reason PUBLISEPTIC TANK.SEEPAGE PIT OR FtNA Z
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM !=
Signature CONNECT ADDITIONAL BLDG,OR
OWNER-BUILDER DECLARATION
WORK To HOUSE SEWER ;
OVERFLOW SEEPAGE PI1.DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN..CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, BUlsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fil it 61 c '1
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ 1,as owner of the property,or my employees with wages as i F
their sole compensation, will do the work and the structure n_
is not intended or offered for sale (Section 7044, Business _
and Professions Code). OWNER'S Permit g "tC '
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FE -
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
p p OWNERS AGENT
issued (Sec. 3097, Civ. C.). ADDRESS
Lender's Name
Lender's Address
I certifyth f hover ad this application and state that the
above into natio►(is arrest. I agree to comply with all County
ordinance on Stat laws regulating Plumbing and Sewers,
and here a thor” e representatives of this County.to ent
upon tho -m ntioned property for inspection 71rpose
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Sig ature ofPermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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