HomeMy Public PortalAbout9810 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
a certified copy thereof (Sec. 3800, LRq C.) 92-0002 DPWgigg APPLICATION FOR PERMIT
Policy No. ° 'Company.
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
-'i
ertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date ( .Applicant rFADD
FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEM ON FROM WORKERS'
COMPENSATION INSURANCE I[ rile ' STATION DEPTH
(This section need not be�.ompieted if the work involved by the W NHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) OWER
I Certify that In the performance of the Work for which this EARETYPE OF CONNECTION IPNGTO FROM
permit is issued, I shall not employ any person in any mannerY CURB P L. M.L.To P.L.
so Os to become subject to the Workers'Compensation Laws. ! f'7 N P ) CO.IMP.NO. JOB NO.
Date Applicant TRUNK PERMIT NO. ROAD PERMIT NG.
NOT{CE TO APPLICANT: If, after makin this Certificate Of AFFIDAVIT WAIVER EA5EMENY RECORDINSTRNODATE
g TEL.NO.
Exemption, you should become subject to the WorkersLEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO.
comply with such provisions or this permit shall be deemed Hwv.QRST.WIDENING
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 Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR• CONNECTION CHARGE FEE
License Number LIC.Class ADDRESS ��, REIMBURSEMENT FEE
y, 1 DISTRICT NO. GROUP MAP - PROCESSED BY
Contractor 'Date 2 tz L CITY TEL NO. 44 BK PG 4 y
El am exempt under Sec. SU _of the L.A.Co. LICENSE NO. 2 Z CLASS
NO. DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the FINAL J
HOUSE SEWER CONNECTING TO ,5') �- DATE u' C ' r � VALIDATION
B. & P. Code for the following reason PUBLIC SEWER r.6
SEPTIC TANK,SEEPAGE PIT OR J
PITS AND/OR DR.AINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM ^ -
Signature CONNECT ADDITIONAL BLDG.OR �z'
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER fj z
OVERFLOW SEEPAGELD
FIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL, ANHOLE ;
Law for the following reason (Sector 7031.5, Buisness and Pro- ALTER,REPAIR OR AOUSE f
fessions Code): SEWER OR DISPOSAi�it_•}_•?. 4
❑ !,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 i
and Professions Code). OWNER'Srmit s �- 0 Z y t r-
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATIOTAL FEE �`. r „F»�1(`S 4 - !TO
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A WITH THE HEREIN NAMED CONTRACTOR TO yBusiness and Professions Code). CONNECT THE ABOVE DESTING DWELLING TO THE PUBLIC SEWER. +. a-s� a 5;CONSTRUCTION LENDING AGENCYrAW f3 I hereby affirm that there is a construction lending agency SIGNED THIS AY OF 19�
for the performance of the work for which this permit is OWNER OR
OWNERS AGEN1
issued (Sec. 3097 Civ C.), � �
7 , f' ! ADDRESS ar w:,
Lender's Name,/ [Ir� .1 .!
Lender's Address
`Y 0,``I
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
uponAhe above-rnp_aican property for inspection purposes.
ignature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE