HomeMy Public PortalAbout9727 RICHMOND WAY_Sewer__ WORKERS' COMPENSATION DECLARATION
1 here affirFp that I have a certificate of consent to self1
id, qr a certificate of W r s'Compensation Insurance, or 76A642D S
Me yife�fI e eo +fp3Q00, jrabC"� Y, s°B(REV.B/B" APPLICATION FOR PERMIT
Polic No.^ om
Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
LJ �'_ertifieO cop is filed with he county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depar, ent +,!
DaI l Applico v_ l,�' FOR APPLICANT T FIL ,fN CONNECTION DATA
C'EAFICATE OF EXEMPTION FROM WORKERS' FADDRE
ING �' STATION DEPTH
COMPENSATION INSURANCE ESS
(This section need not be completed if the work involved by the7 7 ! MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.)
LOCALITY y _ LOWER
I certifythat in the performance of the work for which this EST TYPE OF CONNECTION LENGTH FROM
P CROSS 5T.� -d '{"" �.��.--•• Y. CURE R L M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. E tP.C.NO.
'1"il-- -,.r' iy CO.IMP.NO. JOB NO.
.-�* '+ /; TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ESS it
NOTICE TO APPLICANT: If, after makin this Certificate O# go.
AFFIDAVIT WAVER EASEMENT RECORD WSTR.NO DATE
g .... `-,. TEL.Exemption, you should become subject to the Workers' ALCompensation provisions of the Labor code, you must forthwith IPTION LOT NO. HWY.OR 5T.WIDENING
comply with such provisions or this permit shall be deemedrevoked. K TRACT f STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT No.
F LOT NOWON LOT
I hereby affirm that I am licensed under provisions of Chapter f =9 (commencing with Section 7000) of Division 3 of the Busi- ING$ CHARGES
ness and Professions Code and my license is in full force and
effect. ��'f/ \ (5'ff �` ;r"� CONTRACTOR ' _ ;f CONNECTION CHARGE FEE D.
( r ^of >
License Nu fiber LiC.Class_ ADDRESS REIMBURSEMENT FEE O
�'
DISTRICT NO. GROUP MAP PROCESSED BY V
Contrac6Or L sir' 1L-- Date 4L, ' CITY 3,EfCNO. Z
STATE LIC.
BK VG
❑ 1 am exempt under Sec. of he L.A.Co. ucENSE No. r cLA55 �l 4 i ' O
NO. D C 1PTION OF WORK FEE V
Plumbing Coda and/or Sec. Of the PUBLIC SEWER HOUSE SEWER CONNECTING TO �'t/�, DA EL VALIDATION y
_ t
B. & P .Code for the fallowing reason SEPTIC TANK,SEEPAGE PIT OR FINAL/ Z
PITS AND/OR DRA!NFIELD fJ
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR a r'-
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
fessions Code): SEWER OR DISPOSAL SYSTEM - rr
❑ I, as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure A
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $
❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE ?i o
licensed contractors to construct the project (Section 7044, 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 OWNERS OR
issued (Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
Lender's Address
I certify that I ha `read this application and state that the
above information correct._I gree to comply with all County 1
ordinances and fates re ulating Plumbing and Sewers,
and hereby a orizw'repre ntatives of this County to enter
upon the ob -me6tione property for inspection purposes.
ure of verryrLltee Date SEE REVERSE FOR EXPLANATORY LANGUAGE