HomeMy Public PortalAbout9822 RICHMOND WAY_Sewer__ WORKERS'COMPENSATION DECLARATION
! hereby affirm that I have a certificate of consent to self
insure, or atrert,ificatp of Workers'Compensation Insurance, or _6A`I<D
a certified copy thereofSec. 3800,Ob,C.) 9-00,2DPW 6/88 APPLICATION 'FOR PERMIT
Policy No. t a mpany xa--ifyi
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
El Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. n
Date ,E-" ApplicanttiM �1�O lt. :j � FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' [ADN
LDING L .yJ STATION DEPTH
COMPENSATION INSURANCE RESS
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) CALITY LOWER
ARESTTYPE OF CONNECTION LENGTH FROM
i certify that in the performance of the work for which this OSS sr. l�' Y. carts P.L. M.L TO P.I.
permit is issued, I shall not employ any person in any manner P.C.,NO.
so as to become subject to the Workers'Compensation Laws. OWNER �. CO.IMP.NO. JOB NO
MAIL 1 TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS \
NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO DATE
CITY � TEL.NO. �""
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO, HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF LOT PERMIT NO.
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and _7
effect. ( CONTRACTOR, CONNECTION CHARGE FEE
License Number U6 Lic.Class ADDRESS Z�r ?_ REIMBURSEMENT FEE
Contractor I ate L1 t �CI �,! �� J��f''�1 DISTRICT NO. GROUP MAP PROW
ED BY
-I L- CITY 1 El.NO. 4" � I.,oQ - ' BK PG
1;�'^.,
I am exempt under Sec. J _of the L.A.Co.
STATE , act; /f LICENSE NO. CLAS$ ' .. �.
1
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO d �'�> DATE' '� +•. VAL DATION ;
B. & P. Code for the following reason PUBLIC SE WEIR )CI
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELO /
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELO ► � U' " t '
1 hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRY-WELL,MANHOLE I sr
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
f SEWER OR DISPOSAL SYSTEM
essions Code): � }•t _.a ,;.
❑j 1,as owner of the property,or my employees with wages as }
their sole compensation, will do the work and the structure t' 3
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit g J3 _
El4 50
1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE (EE N -'
licensed Contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ;' ,."rl_I
Business and Professions Code). 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 theperformance of the work for which this permit is OWNER
OWNERS AGENT
issued (sec 3097, Civ. C.)
ADDRESS
Lender's Name C- 1�s v *yr,,
4rAr.
Lender's Address
-
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 her by authorize representatives of this County to enter
upon t above-menti ^ ¢property for inspection purposes.
l" Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE