HomeMy Public PortalAbout9802 RICHMOND WAY_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76AeA2D
a.'Jicy ied copy thereof(Sec 3800, Lab C. 9,_ 0 nPwe,ae APPLICATION FOR PERMIT
P'q,'dicy No. .` Company ��G'L�°�_�
Certified copy is ereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY {
department.
CERTIFICATE' OPIEXEMP N FROM WORKERS' ��� BUILDING „FOR ^ r�i NT TO FILL IN CONNECTION DATA
Pare gg APPLICANT
COMPENSATION INSURANCE ADDRESS t ( ✓d, STATION DEPTH
(Tt4is section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
p*rnit is far one hundred dollars ($100)or less.) LOCALITY LowER
NEAREST y TYPE OF CONNECTION LENGTH FROM
I*, rtify that in the performance of the work for which this CROSS ST. Lvc t 7 v CURB P.L. M.I.TO P.L.
otwmit is issued, I shall not employ any person in any manner P.C.No.
so ac to become subject to the Workers"Compensation laws. OWNER V L CO.IMP,NO. JOB NO.
Date - -- - _ Applicant_
ADDRESSCIO T, '� TRUNK PERMIT NO. ROAD PERMIT NO.
NONCE 70 APPLICANT: If, after making this Certificate of CITY YS
TES.NO. fi�
AFFIDAVIT WAIVER EASEMENT RECORD.WSTR.NO. DATE
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
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.
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 Busl- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. C CONTRACTOR - CONNECTION CHARGE FEE
License Number Lic.Class ADDRESS ,_; REIMBURSEMENT FEE
DISTRICT NO. GROUP BK MAP r.PROCESSED BY
Contractor to t CITY �t TEL.NO. �< Fl. 0 r
I � �� PG
STATE ry LIC. t^ .� �. q 1 � I O
❑ Pam exempt under Sec. of The L.A.Co. LICENSE NO. L cLAss
NO. DESCRIPTION OF WORK FEE •_f C,j
Plumbing Code and/or Sec. of the FINAL
HOUSE SEWER CONNECTING TO `' DATE ,eT^, (" V VALIDATION
B. & P. Code for the following reason PUBLIC SEWER _ sr
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date BY
HOUSE SEWER CONNECTING TO
Signature
DISPOSAL SYSTEM
•signature CONNECT ADDITIONAL BLDG.ORP U,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER —
f
I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL.DRYWELL,MANHOLE VVV r '>
Low for the following reason (Becton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE ;,
fessions Code):
SEWER OR DISPOSAL SYSTEM
❑ i,as owner of the property,or my employees with wages as
4,
•'(-
t eir sole compensation. will do the work and the structure
s not intended or offered for sale (Section 7044, Business
ind Professions Cade), OWNER'S Permit $
❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE j t'S' `' " lfiU
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 �,�"z t1:.4.•1u
CONSTRUCTION LENDING AGENCY L >M
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which thisermit is OWNER OR
issued (Sec. 3097 CivC.). p OWNERS AGENT 4
ADDRESS
Lender's Name .
Lender's Address
—
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
Upon f. above_Mentioi,T.e,d-p—perty for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE