HomeMy Public PortalAbout9813 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 76A6420
a certified co thereof Sec. 3800, L b C. 92-0002 DPW 6/88
Policy No.(O0`LK7 -Y (Sec.
��a-K_,'�, T. r–,)r-,( APPLICATION FOR PERMIT
❑ SEWER - SEWAGE DISPOSAL
Certified copy is hereby furnished.
D'Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY +d
department. f:
Date. Z_A 7 C'J'L Applicant t r 1 l�Lka[ ! �t FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEM TION FROM WORKERS' i ` STATION DEPTH
Y)
COMPENSATION INSURANCE ADDRESS "� 9 G)` _)N�i
(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
NEAREST - TYPE OF CONNECTION LENGTH FROM
certify that in the performance of the work for which this CROSS ST. ,0! Y. torte PA 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. ^fir ��� P.C.NO
OWNER (;�, E CO.IMP.NO. JOB NO,
Date Applicant ADDRESS �V/ 4 r L' '� i TRUNK PERMIT NO ROAD PERMIT NO,
NOTICE TO APPLICANT: If, after making this Certificate of CITY ?f ( TEL.NO. l._.eu.— AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO,
comply with such provisions or This permit shall be deemed HWY,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. ��Cq- CONTRACTOR 1 r�"�, n k \ CONNECTION CHARGE FEE
License Number IP-)CIqG5 Llc.Class ( , ADDRESS Z:!r �l REIMBURSEMENT FEE
�(}�ate 4- [ ' DISTRICT NO. GROUP MAP �pROCESSE
,C�-O}ntraClar 1 1 `C- - (,�D�,�^} 1.7 CITY ' TEL.NO. -44
'� BK PGSTATE Jg
L�1 I am exempt under Sec. t�-'0 _of the L.A.Co. LICENSE NO. - LIC. 1.,� V �' 1 f
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL, ✓
i�
HOUSE SEWER CONNECTING TO r^1't DATES VALIDATION r•
B. & P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL"'
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature_ CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
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
❑ 1,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure Fit
is not intended or offered for sale (Section 7044, Business 1 `T MC
and Professions Code). OWNERS Permit S w3 r!f�}
El I,as owner of the property, am exclusively contracting with AUTHORIZATION L TOTAL FEE T111TAL .34 - !TO
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO n. z'
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. I:ri'> E:.•+ «-�i'y.'i
CONSTRUCTION LENDING AGENCY
oPON. 1=
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 OWNER OR
sued (Sec. 3097, Civ, C. OWNERS AGENT
).
ADDRESS L
Lender's Nar47,(a�
n�z..('��_
Lender's Address 90
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
opo a above mentlony Dperty for inspection purposes.
rJ
/� Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE