HomeMy Public PortalAbout9723 RICHMOND WAY_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirrvl that I have a certificate of consent to self
ins u qqtr1 a tertificate of Workers'Com en anon Insurance,.or•---.- 76A6420
Pblic+yifRCPy., e o12 s€ an$�TCE 808(REV.8!81) APPLICATION FOR PERMIT
Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depart nt.
Dare ' =AppIicont tom- FOR APPLICA I TO, ILL IN CONNECTION DATA
CE IFICATE OF EXEMPTION FROM WORKERS'
BUILDING ^ �+ J STATION DEPTH
COMPENSATION INSURANCE ADDRESS .- ! `L""
This section need not be completed if the work involved b the UPPER
( P Y MANHOLE REFERENCE
permit is for one hundred dollars ($100)or less.) LOCALITY . y LOWER
that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
I certify P CROSS ST. _ � �, , ;�' Y: CURE v.t. M.L.TO P.1-
permit is issued, I shall not employ any person in any manner �✓
C.
so as to become subject to the Workers'Compensation Laws. a F.d NO.
OWNER ;p �" �--y>""�;r CO.IMP,NO. JOB NO.
MAIL m TRUNK PERMIT NO. ROAD PERMIT NO,
Date Applicant A°°KESS ' 1�1`' y
NOTICE TO APPLICANT: If, after makingthis Certificate of �^ ✓ - j T !s AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CITY � TEL NO. C f
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO,—'--,4/ HWY,OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT `
LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOONO.W OF N LBLDOTGS PERMIT NO.
I hereby affirm that I am licensed under provisions of Chapter usE of ^r�
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS �l CHARGES
ness and Professions Code, and my license is in full force and
-R +`_" CONNECTION CHARGE FEE
effect. '91r .� CONTRACTOR d v �,.
License N r ber f iic.Class ✓ REIMBURSEMENT FEE
't, 11 ADDRESS O
ContrOCZL..3,z _'"L Date"' CITY DISTRICT NO. GROUP MAP PROCESSED BY
"" `14.NO. BK PG Z
El am exempt under Sec. of the L.A.Co. LICENSE NO. CL 55 F®F
V
Plumbing Code and/or Sec. ofthe NO. ESCIPTI N CYr WORK FEE INA W
HOUSE SEWER CONNECTING TO '�, + DAVALIDATION_ d
PUBLIC SEWER 9
in
B. & P. Code for the following reason SEPTIC?ANK,SEEPAGE PIT OR FIN Z
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM '
Signature CONNECT ADDITIONAL BLDG,OR JTRACTORTO OWNER-BUILDER DECLARATION WORK TO HOUSE SEWEROVERFLOW SEEPAGE PIT,DRAINFIELDI 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 HOUSEfe.ssions Code): SEWER OR DISPOSAL SYSTEM
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). OWNER'S Permit $
AUTHORIZATIONi, as owner of the property, am exclusively contracting with TOTAL FEElicensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CBusiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLICONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF for the performance of the work for which this permit iS OWNER AGENT E <
issued (Sec. 3097, CIV. C.). OWNERS AG tJT
ADDRESS
Lender's Name
i
Lender's Address
—
I certify that I ve read this application and state that the
above informal"�ni ect I agree to comply with all County
ordinances a ws regulating Plumbing and Sewers,
and hereby the/reresentatives of this County to enter +
upon the ob e- tid property for inspection pur ses.
Sig t re of Pe ttee Date SEE REVERSE FOR EXPLANATORY LANGUAGE