HomeMy Public PortalAbout9816 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 76A642D
a certified copy thereof(Sec. 3800, Lab C.) �b 9P-'�0ZDPW 6,88 APPLICATION FOR PERMIT
Policy No1Qr�� Company zC - i:,o Al,
Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Ea) Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY +�
department. .
Date Applicant rk FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMP ON FROM WORKERS' BUILDING" - 9.r 1 STATION DEPTH
COMPENSATION INSURANCE ADDRESS ( l
(This section need not be completed if the work involved by theMANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY
certify that in the performance of the work for which this NEAREST ti(' TYPE OF CONNECTION LENGTH FROM
CROSS ST. 11 Iq Y. CURB PL WE.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. P NO.
OWNER •—�►� �'' CO.IMP.NO. !OBB NO.
MAIL C� TRUNK PERMIT NO. ROAD PERMIT NO.
Dote Applicant ADDRESS a _
NOTICE TO APPLICANT: If, after making this Certificate of AFFIDAVITWAIVER EASEMENT RECORD.INSTR.NO. DATE
Exemption, you should become subject to the Workers' CtTr�. TEL.NO.
Compensation provisions of the Labor code, you must forthwith LEGAL
p P Y DESCRIPTION LOT NO.
comply with such provisions or this permit shall be deemed
HWY.ORST.WIUENWG
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO,OF BLDGS. PERMIT NO.SIZE OF LOT NOW ON LOT
1 hereby affirm that I am licensed under provisions of Chapter USE OF
9 (Commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
mess and Professions Code, and my license is in full force and
ef`ect. L ft CONTRACTOR (Yyl �• CONNECTION CHARGE FEE
License Number _Lic.Class fr'-S�, � � '�` REIMBURSEMENT FEE
! �] { ADDRESS
Contractor cyte O1t� q 0 � � DISTRICT NO. GROUP MAP PROCESSED BY
CITY TEL NO. fff
�� BK PG
C STATE
9 am( under$eC.� ___Of the L.A.Co. L CENSE NO. CLASS 0 ('3 l,^ 0
Plumbing Code and/or Sec. of the NO DESCRIPTION OF WORK FEE FINAL0
HOUSE SEWER CONNECTING TO DATE ) i VALIDATION
B. 8 P. Code for the following reason PUBLIC SEWER .'% " Q
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINRELD FINAL 711
Date HOUSE SEWER CONNECTING TO BY /' l
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG,OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ►•, � ,�
6hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE y ��
Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Cade)] SEWER OR DISPOSAL SYSTEM
C1 1,as Owner of the property,or my employees with wages as u
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
�;T and Professions Code). OWNERS Permit $ �}
L 1 1,CIS owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE %'� C l •)9: �L�`"-''
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, ' (-�'GE
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 OWNER OR
issued (Sec. 3097 Civ. C.) OWNERS AGENT
ADDRESS X12 t ;"
o _,
. .�
(tinder's Name n1Ler
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,
anci hreby authorize representatives of this County to enter
Upon fete above-mens I"perty for inspection purposes,
y.-
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Sign"lure of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE