HomeMy Public PortalAbout9719 RICHMOND WAY_Sewer__ WOR-URS'COMPENSATION DECLARATION
I hereby affi• that I have a certificate of consent to self
ins ,"q�zpe rrtificate of Workers'C_grnpensation Insuranegr.or. 76Aa42D
c fi p9y th repo (Sec. 3 .�b.c.) CE 808(REV 8,81) APPLICATION FOR PERMIT
ohcy t ompan _1-L_. l L '�r�_� 4 r:; - o�E
Certified copy Is hereby furnished. SEWER - SEWAGE DISPOSAL
ertified/'copy is filed with .,e county buildinf itnspeclion COUNTY OF LOS ANGELES BUILDING AND SAFETY
888$$ ��O
ent `
DateApplica t :� ja = FD
FOR APPLIC��4 T T ;Flit IN CONNECTION DATA
TIFICATE OF EXEMPTION FROM WORKERS' ING s
COMPENSATION INSURANCE ESS a STATION DEPTH
(This section need not be completed if the work involved by the �y MANHOLE REFERENCE LOWER
UPPER
permit is for one hundred dollars ($100)or less.) LITY
EST TYPE OF CONNECTION LENGTH FROM
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I certify that in the performance of the work for which this S ST. - - „` 3-�•" ..qr'-=-w,. Y. CURB P.L. M,L.TO P.L.
permit is issued, 1 shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. ER CO.IMP.NO. JOB NO,
MAIDote_ Applicant ESS y TRUNK PERMIT NO ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after making this Certificate Of �ryAFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO DATE
g j),r' TEL.NO. ryExemption, you should become subject to the Workers' ALCompensation provisions of the Labor code, you must forthwith IPTION LOT NO. HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemedrevoked. TRACT STATE ENCROACHMENT
NO.OF BLDGSPERMIT NOLICENSED CONTRACTORS DECLARATION F LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter f9 (commencing with Section 7000) of Division 3 of the Busi- INGS CHARGES
ness and Professions Code and my kense is in full force and
effect. = CONTRACTORCONNECTION CHARGE FEE >.
fL
License NuNtber LIC.CIaSS_' ADDRESS REIMBURSEMENT FEE O
k*
ContractDC ,}� + DISTRICT NO. -GROUP �1AAP PROCESSED BY U
CITY L.NO.
8K PG 0
STATE r- LIC. . '
El am exempt under Sec. of the L.A.Co. LICENSE NO CLASS
It—
NO. SCR TIO OF O FEE IL1
Plumbing Code and/Or Sec. of the FIN U
HOUSE SEWER CONNECTING TO '`] DATE ! VALIDATION
B. & P. Code for the following reason PUBLIC sEwER I ,�J
SEPTIC TANK,SEEPAGE PIT OR FI 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 PIT,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, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 4
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ I, as owner of the property,or my employees with wages as �'!. r_+s
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business o
and Professions Code). OWNER'S Permit g
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE ' )� 3 1�'
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 Poo 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
I certify that .,have r this application and state that the
above infor prion i f irect. I agree to comply with all County
ordinances nd S, ♦ laws regulating Plumbing and Sewers,
and her. out ori a representatives of this County to enter
upon th bovg- ntioned property for inspection purposes.
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nature Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE