HomeMy Public PortalAbout9726 RICHMOND WAY_Sewer__ WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
1 a er F d co�pyythereof (Sec. 3800C.) - CE 800(REV-B,B,) APPLICATION FOR PERMIT
d d= 'Company s f .{ ,,ss. y ti° + Y 's
❑ ertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county build;n inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Date t� pplicant �'�'"1` s FOR APPLICANT TO FILL IN CONNECTION DATA
ERTI ICATE OF EXEMPTION FROM WORKERS' BUILDING �^ o
COMPENSATION INSURANCE ADDRESS STATION DEPTH
(This section need not be completed if the work involved by theUPPER
permit is for one hundred dollars ($100)or less.)
LOCALITY t MANHOLE REFERENCE LOWER
I certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROMCROSS Sr. " %L 't' }s'e` Y. ruRB P.L. WL TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation LOWS. Jer P.C.NO.
OWNER � .�,,.�'-"L-- -•t. L/, CO,IMP.NO. JOB NO.
MAIL L
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Date Applicant ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO.
L. lam.
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: if, after making this Certificate of OTY �j .[1TEL.NO.
Exemption, you should become subject to the Workers' LEGAL
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
revoked. BLOCK TRACT ��. '� STATE ENCROACHMENT
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LICENSED CONTRACTORS DECLARATION NO.OF BLDGSPERMIT NO.SIZE OF LOT NOW ON LOT r
I hereby affirm that I am licensed under provisions of Chapter USE OF "I
-
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 r
effect.
," yy 4A CONTRACTOR �.(' � C CONNECTION CHARGE FEE
j/�� }
License NyFr>ber Lic.Clasr- ADDRESS - `k• �� REIMBURSEMENT FEE
!� DISTRICT NO., GR MAP PROCESSED BY
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Contract6t��Q_t),,r`�_ e Date ' - i
CITY -,4��'-C TEL NO. `�"& %'•�' PG O
❑ I am exempt under Sec. of the L.A.Co. LICENSTATESE
4 ' uC. s of
LICENSE NO. 1� ,l- CLASS
NO. DESCRIPTION F WORK FEE
Plumbing Code and/or Sec. of the FINAL,'' • VALIDATION a
HOUSE SEWER CONNECTING 10 1 DATE
PUBLIC SEWER
B. 8 P. Code for th ;tollgw n reason SEPTIC TANK,SEEPAGE PIT OR ,' L z
PITS AND/OR DRAINFIELD
Dale FINHOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature j4 �-- �. �' CONNECT ADDITIONAL BLDG.OR ,
'WNER-BI AER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD _
I hereby offirmr'that I ani 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
fessions Code): SEWER OR DISPOSAL SYSTEM
F
❑ I,as owner of the property,or my employees with wages as J
their sole compensation, will do the work and the structure d, 5 0
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit S „ y'',r ;a M
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors 10 construct the project (Section 7044, HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO t IJ r l
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ►
1 hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performcince 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 inform tion is correct. I agree to comply with all County
ordinances St laws regulating Plumbing and Sewers,
and here b autbroriz representatives of this County to enter
upon the�boye-me tioned property for inspection purpos s.
nature of ,rmittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE