HomeMy Public PortalAbout11201 WINDSOR LN_Sewer__ WORKERS'COMPENSATION DECLARATION
10,4reby Offirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
PLId° y thereof(Sec. 3800 CE OP�808(REV 8f91) APPLICATION FOR PERMIT
!,�Pmpany
ertifiecl copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certif cop is filed with the my building irlgpectivn COUNTY OF LOS ANGELES BUILDING AND SAFETY
Dateart ent. " f `
' ' `Applicant po �r° (`. " ' FOR APPLICANT TO FILL IN CONNECTION DATA
C TIFICATE OF EXEMPTION FROM WORKERS' BULDINGL #r STATION DEPTH
4 COMPENSATION INSURANCE ADDRESS
(This Section need not be completed if the work involved by they^"•" '"'4` MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY OWER
1 cert/ that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
certify P CROSS T. .. Y. CURB P.I. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
subject to the Workers' Compensation Laws. l P.C.NO.
so as to become sub
I P OWNER ..n�>,- "L.!'-4s"�- CO.IMF.NO. JOB NO.
- t { TRUNK PERMIT NO. ROAD PERMIT NO.
MAIL
Date ApplicantADDRESS
NOTICE TO APPLICANT: If, after makingthis Certificate Of %,' C' AFFIDAVIT WAIVER €ASEMENT RECORD.INSTR.NO. DATE
CITY �' TEL N0. d� '. �
Exemption, you should become subject to the WorkersLEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO lF + HWY.OR ST WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
. .
LICENSED CONTRACTORS DECLARATION NOOF BLDGSPERMIT NO.SIZE OF LOT NOW ON LOT
1 hereby affirm that I am licensed under provisions of Chapter USE OF a f
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS " d� CHARGES
ness and Professions Code, and my license is in full force and
effect. j�`}3 CONTRACTOR CONNECTION CHARGE FEE
License N ber--� I ic.Class �`s•. ADDRESS REIMBURSEMENT FEE
f,+` 7 T,A1Ei.. GROUP MAP PROCESSED BY U
COntraC[�4� "'1.-. Date- Wit-"` T"` CITY 1E '
z
El Co. STATE
. LIC. I `� v'r I am exempt under Sec" of the L.A. LICENSE NO. CLASS 7 BK PG O
h
Plumbing Code and/or Sec, of the No, ES IPTIbN O WORK FEE F AL , V
HOUSE SEWER CONNECTING TO DATE VALIDATION
PUBLIC SEWER
B. & P. Code for the following reason - SEPTIC TANK,SEEPAGE PIT ORFly z
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO B r
PRIVATE DISPOSAL SYSTEM .ap�
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License EXTNFLOESSPOOL.DRYWEDLRAMAN OLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM 1, % ,A
❑ 1,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure j
is not intended or offered for sale (Section 7044, Business - r 4
and Professions Code). OWNERS
Permit $ � ,/ .:'7, 5 �...
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE j c' 1. T
licensed contractors to construct the project (Section 7044, t HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTR CTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. f ¢£
CONSTRUCTION LENDING AGENCY SIGNED THIS Pilo
I hereby affirm that there is a construction lending agency DAY OF 19_
for the performance of the work for which this permit is OWNER A
OWNERS AGENT
issued (Sec. 3097, Civ. C.). ADDRESS
Lender's Name
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
ordiyher
'and State laws regulating Plumbing and Sewers,
andy or ze representatives of this County to enter
upo �}'ove- 'entioned property for inspection pu poses.
/gnat ,Eo Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE