HomeMy Public PortalAbout9807 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 76A6421)
a certified coy thereof Sec. 3800, Lab C.) { 92-0002 DPW 6/66 APPLICATION FOR PERMIT
Policy No.if��ti'}_'7�.' C(rMpany �c}�. afk
El Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date t� 10,Applicant—)<<`�� .L'rrYtCt 1 (k V )I FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGF r STATION DEPTH
COMPENSATION INSURANCE ADDRESS (� K-a) " EL� ti IV 1 T
(This section need not be completed if the work Involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY LOWER
certify that in the performance of the work for which this NEAREST r ,^r TYPE OF CONNECTION LENGTH FROM
Y P• CROSS 5T �LJL�J /�G. C`-V y, Cog 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. NO.
COIMP
OWNER T, . ,NO. JOBB NO.
MAIL �" TRUNK PERMIT NO. ROAD PERMIT NO.
,.Date_Applicant ADDRESS `
NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR NO DATE
CITY TEL.NO. ahsa�
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
1 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. "] ` Q CONTRACTOR ( �{''' ,� CONNECTION CHARGE FEE
License Number }"Ck h �• Llc.Class 1�J ADDRESS F '�' REIMBURSEMENT FEE
COniraClOr1 .L` �L Date �� �'-! DISTRICT NO. GROUP MAP '* PROCESSED BV
CITY . -„ C.I V TEL.NO. ^ ,t} BK PG
'tel STATE LIC. (1. , ( }
❑ I am exempt under Sec. , —of the L.A.Co. LICENSE NO. 2—�l CLASS 4D °°f66 LV (' L Y 0
NO. DESCRIPTION OF WORK FEE 0.
Plumbing Code and/or Sec. of the HOUSE SEWER CONNECTING TO DATE I
tVALIDATION
PUBLIC SEWER o;, t..
B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL Q
PITS AND/OR DRAINFIELO
Date HOUSE SEWER CONNECTING TO BY r _ Ld
PRIVATE DISPOSAL SYSTEM CL
Signature CONNECT ADDITIONAL BLDG.OR ® j'
OWNER-BUILDER DECLARATION
WORK ro HOUSE seweR
OVERFLOW SEEPAGE PIT,DRAWFIELD
Ir hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE it^
Law for the fallowing reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
'D 1,as owner of the property,or my employees with wages as e
their sole compensation, will do the work and the structure =_Ui " "
is not intended or offered for sale (Section 7044, Business 1 TLy
and Professions Code), OWNERS Permit $
I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE S 'T bT-f,l'L. 34 . 50
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. ':r�!£:.`«^
`E
CONSTRUCTION LENDING AGENCY qr f_
1 hereby affirm that there is a construction lending agency SIGNED Tt115 DAY OF 19
for the performance of the work for which this permit Is OWNER
OWNERS AGENT
issued (Sec. 3097 Civ. C.).
Lender's Name {{�� {
C-r`.+' C ADDRESS _..JL,th{ 3;•IaY .t,d .C. tri`r'
R.
Kw.
Lender's Address
1 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
uponnhe above-mer)l�ed property for inspection purposes.Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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