HomeMy Public PortalAbout9821 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.) 92-6408 DPW 6/88 APPLICATION FOR PERMIT
Policy Nol ompany �{� � � _
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
a Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY °
department. _
Date f1 Applicant �r f�i°� t FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEM ION FROM WORKERS' BUILDING
'* S?ATION DEPTH
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($1100)or less.) LOCALITY LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. T-S (. L i 1 Y. CURB P.I, M.L.TO P,L.
permit i:; issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. OWNER CO IMP.NO, JOB NO
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS ` j"'7
NOTICE: TO APPLICANT: If, after making this Certificate of ---T— AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO. DATE
c
Exemption, you should become subject to the Workers' CITY TEL.NO.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
NO.OF BLDGS. PERMIT NO.
LICENSED CONTRACTORS DECLARATION SIZE OF LOT Now ON LOT
I hereby affirm that I am licensed under previsions of Chapter SSE 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, .y e Y-1 CONNECTION CHARGE FEE
License Nuumber LIc.Class "ry ��� i.� - ! 1 REIMBURSEMENT FEE
q ,e'� ADDRESS
`�1 r'I ` { 1 ,�t DISTRICT NO, GROUP MAP PROCESSED BY
Contractor. Date { k- tr L— CfTY {�}' c ). TEL.NO. `-4 BK PG
❑ I am exempt under Sec. L) _of the L.A.Co. LICENSE NO. �r� � CLASS ,�
t
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL
PBL E SEWER SEWER fs,r'"�CONNECTING TO r DATE(' fi; VALIDATION Cr
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR E FINAL 1-
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY < p LU
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG OR l r, CL
C!)
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAfNFIELD y
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE f w
Law fu the fallowing reason (Secton 7031.5, Buisness and Pra- ALTER,REPAIR OR ABANDON HOUSE
fessions Cade): SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as n i
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $ L3 �? ITEM`
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE : -
�Tl
i 4�i'k :,,4_�,�licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTO
Bu-iiness and Professions Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
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
\
Lende's Name L 7 A\1 ADDRESS
Lender's Addresst "'
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
upon the above-me ."rsed property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE