HomeMy Public PortalAbout9722 RICHMOND WAY_Sewer__ WORKERS'COMPENSATION DECLARATION
1�heteby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A6,120
at t{fl�etd, cop thereof Sec. 3800, Lab C.j f fCE BDB(REV.8/81 APPLICATION FOR PERMIT
jPtoFrya� iSG pany .J�6 ,-, ., — c zt < �s
kS-Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy,:is filed With the c �bntyi5'6 'Ing inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depart end. r
Date ✓ Y Applicant FOR APPLIC�IkN�T TO FILL IN CONNECTION DATA
CERT FICATE OF EXEM ON F WORKERS' BUILDING t
COMPENSATION INSEJI2ANCE ADDRESS ' < '} STATION DEPTH
(This section need not be completed if the work involved by the " UPPER
permit is for one hundred dollars ($100)or less.)
LOCALITY �. - MANHOLE REFERENCE LOWER
NEAREST ' TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST L-- � Y. CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. P.C.NO
OWNER '� -� � +� "�-� CO.IMP..NO. JOB NO.
MAIL.
Date——Applicant ADDRESSTRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after making this Certificate of CITY
TEL
y AFFIDAVIT WAIVER EASEMENT RECORD.INSTR NO. DATE
"Y . -
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DFSCRIPTIION LOT NO. / HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK � TRACT "^""' �' �^` STATE ENCROACHMENT
NO.OF BLDGS, PERMIT NO.
LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE of
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. : CONTRACTOR 4��^`,'-,-0• ,-- �.�:"i w,,,t- CONNECTION CHARGE FEE >-
License NVhiber" Z Lic.Class_
ADDRESS REIMBURSEMENT FEE
s ,T'CP"G ,.r`'
�3
p, ' t` Date g- � rj { ,j. DISTRICT NO. GROUP MAP PROCESSED BY
Contract, '^" ., .fi: i a duly.� ..,
-- CITY l l,.. TEL.NO.
�. BK PG
❑ I am exempt under Sec. of the L.A.Co. CENSE NO. ° krw ' .• CLASS t1 �L `
Plumbing Code and/or Sec. of the NO. DESCRIPIricN OF ORK FEE FINAL
` HOUSE SEWER CONNECTING TODATE VALIDATION R.
B. 8 P. Code for thollowing�ason
PUBLIC SEWER �- ' - fA
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD F , .e
HOUSE SEWER CONNECTING TO
g rF PRIVATE DISPOSAL SYSTEM L f
Signature ( E _}�� CONNECT ADDITIONAL BLDG.OR
"OWNW ESR ydJLDER DECLARATION WORK To HOUSE SEWER
e" < r�" `
I hereby affirm that I arM OVERFLOW SEEPAGE PIT,DRAINFIELD I,
exempt{YOm the Contractor's License EXTN.,CESSPOOL DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM hfi
❑ 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). OWNERS Permit $
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE l
licensed contractors to construct the project (Section 7044, I 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
issued (Sec: 3097, Civ. C.). OWNERS AGENT
ADDRESS
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above informatiorr is correct. I agree to comply with all County
ordinances andXcite laws'rdpguioting Plumbing and Sewers,
and hereby oke horize.,iepre*ntatives of this County to enter
upon the above-mentlioned7 roperty for inspection purposes,
Sig tore of Permpfee Dat--e ,, SEE REVERSE FOR EXPLANATORY LANGUAGE