HomeMy Public PortalAbout9718 RICHMOND WAY_Sewer__ 1 WORK IvS' COMPEhJSA1 'LARATION
+!` I hereby'affir;p�tfict I have a ctPTr'-me of consent to self
} +nsurc, oro cert ficate of Workers'Corrpensatlan Insurance, or
p -�ye,ifjeq.tV thereof (Sec. 3800, Lac. �p� � E3o�;RF''8 � APPLICATION FOR PERMIT
'!S o.- �' - ompany_�_r r ,( _R,(.� c...x_ :��� s
rQ Certified opy is hereby furnisheJ SEWER - SEWAGE DISPOSAL
r r
Certifiedrrlcopy is filed with r,he ouy burldrng inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depart nt
A
I ` w dV
Date pelican ( ;..��:.`� -� -`' � FOR APP i�iANT TO Flll IN CONNECTION DATA
ERTIFICATE OF EXEMP ON FROM WORKERS rr
COMPENSAT; N INSURANCE ADDREISs '? ' srAnoN DEPTH
(This se ion need not be Cor" leted'if the work involved by the 6"t MANHOLE REFERENCE UPPER
jiermll i5 for one hundred d !ars ($100) or less.) tcxaury �_. LOWER
NEAREST TYPE OF CONNECTION r•° LENGTH FROM
it T ce,4ify that in the r'6rfor ;ance of the work for which this CROSS Sr r �.. Y. CURB P.L. R M.L.TO P.L.
permit is issued,I shall not employ any person in any manner
o as to beco pe subject to the Workers' Compensation Lows. Y-- P,C.NO.
/ OWNER r , "r =`"I ''� CO.IMP.NO. JOB NO.
MAIL .` TRUNK PERMIT NO. ROAD PERMIT NO.
ateADDRESS,_—��-Appli cnt _
r U!-
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
OTIC: TO APPLIQANT: tf, after making this Certificate of olTy' TEL•N
xemption, you Should become subject to the Workers' LEGAL F
Compensation prov'sions of the Labor code, you must forthwith DVSCRIPTt N LOT NO. HWY.OR 5T.WIDENING
cop-ply with such provisions or this permit shall be deemed w x
,revoked. BLOCK ': TRACT STATE ENCROACHMENT
PERMIT NO.
LICENSEy�CONO.OF BLDGS.
CONTRACTORS DECLARATION slzE of Lor Now ON Lor
ty'1 hereby affirm tha j I am licensed under provisions of Chapter USE OF
,a9 (commencing will{1 .Section 7000) Of Division 3 of the Busl- BUILDINGS71
7 ne5_:and Professions Code, and my license is in full force and CHARGES
(effel, CONTRACTOR \. y CONNECTION CHARGE FEE
c^I` Class_ t
L Eea:'e NiJ r�Tber ADDRESS REIMBURSEMENT FE'e
".+' J ; DISTRICT NO. GROUP MAP PROCE ED BY
Caet cto0 + �". `_Date _ Y t .. �IrY r No
y. ' i
m exempt under Sec. of the L.A.Co. STATE
NO. { C'' ` CLASS
Plu• Bing Code and/o4, c of the NO. ESCRIPTION OF WORK FEE FINAL V
b I HOUSE SEWER CONNECTING TO 7 VALID ION IW
DATE /J
PUBLIC SEWER ! �,�J y� 106
B. P. Code for fol wm rec ^'��
SEPTIC TANK,SEEPAGE PIT OR IIA
FI
PITS AND/CR DRAINFIELD
Z
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
g r CONNECT ADDITIONAL BLDG.OR
Si nature . _ ,
WPJER-�ftfr ')N _- WORK TO HOUSE SEWER _
OVERFLOW
"ti fC .. SFEPA!-
I� 46;IELDhereby Jr thoBNHO
LE
I lowmga' LSec' uisness
and Pro-
Ll
roa
L I,as o rker of th arperty,or.' mplo, es with wages as
s
heir§c+e Cornpe .,Cltion, will do the wor and the Structure
F; not intenaed or offered for Sale (Sect�n 7044, Business ± _ �
I$ and Professions Codi).
I<as owner of the property,a.:;exclusive[ Contracting with i
NTIOnt '
licensed COM!aC1orS to Construct the proj t (Section 70,14, :IS DATE A f+ n JAMED CONTk CTOR TO
E vsmass and Professions Code). - ;HE ABOVE DEiC`. DNEU.iNco .HE PUBLIC,SEWER. j
CONSTRUCTION LENDING AGENgY
�! I hCreeiv effirm that there is a construction ending ager '' vNEDTHIS poll
the 1performance of the work for which this permit is WNER oR
d ls�Lled ('A'•c..3097, Civ, C.). OWNERS AGENT
i Le„der's ADDRESS
? Name____ —� — --
Lender's Address t, P
I certify that I have read this gpplicatian and state that the r 3 >I -
b c,
above information i*correct,,I agree to cotnply with all County
ordinance, and Slat, laws regulating Plumbing and Sewers, {
and hereby authbr'iz 'repr4sentatives of this County to enter
1 upcn the abov ;ment nod property for inspection purposes.
SV n: r of F'-rr[ttt pate SEE REVEk �ORY LA`