HomeMy Public PortalAbout9707 WINDSOR LN_Sewer__ WORKERS' COMPENSATION DECLARATION
I t.ereL#i affirrrm.0thot I have a certificate of consent to self
Insure 10 r,d C Wificate of Workers`Compensation Insurance-or 76A642D
'�f1�61rcay °Mer. of (Sec. 3TC., - CE BOB(REV.B;BI> APPLICATION FOR PERMIT
ocy I� Compant I�si',�Ir+ee 9�9 fy -se• Cis
Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with th gounty build; inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Applicant _ e" FOR APPLIC T TO FI,L�L 1N CONNECTION DATA
C TIFICATE OF EXEMP FROM WORKERS' I
DIN {" STATION DEPTH
COMPENSATION INSURANCE RFss r 7
UPPER
(This section need not be completed if the work involved by the ALITY +? ^! MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100)or less.)
REST-��---" TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this s s --' Y. CURB P L. M.L.TO P L.
permit is issued, I shall not employ any person in any mannersy�
so as to become subject to the Workers'Compensation Laws, NER J.�._ T7k-'�s''_..Y CO.IMP,NO. JOB NO.
RESS �- �' � ` '. TRUNK PERMIT NO. ROAD PERMIT NO.
Date
Applicant AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: if, after making this Certificate of Clry ti"'"• TEL.Nof ?z. ,t,.-- -��
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith
P P Y DESCRIPTION LOT NO. '' HWY.OR St.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACTS STATE ENCROACHMENT
.
LICENSED CONTRACTORS DECLARATION NO.OF BLDGSPERMIT NO.SIZE of Lor Now ON Lor
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Bust- Bu LDINGs CHARGES
ness and Professions Code, and my license is in full force and
effect. t .- . CONTRACTOR <� �, CONNECTION CHARGE FEE d
License N berLIC.Class ADDRESS REIMBURSEMENT FEE O
COnlfdCta "' l' L Dai /!.' wry r / DISTRICT NO. GROUP MAP PROCESSED BY U
.......,w...... 57 _ ,L�`—, `�; CITY . TEL.Iy, . i,:�(. `xro BK PG
❑ 1 am exempt under Sec. of the L.A.Co. uCENSE No. ``" C1A55 a
Plumbing Code and/or Sec. of the t-4g, DESCR1PTION OF WORK FEE FI .Ali *d�1
HOUSE SEINER CONNECTING TO � ��,V DATE VALIDATION CL
PUBLIC SEWER ""'� 41.41
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FIN �-�� Z
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO B f ® c
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ► J s
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License ExTN.,CESSPOOL,DRYwELL,MANHOLE m
Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER;REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business Permit y j
and Professions Code). OWNERS
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE in S
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:
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 AGENTADDRESS
Lender's Name
Lender's Addres r
I certify that I ave re this application and state that the
above inform tion is ydr ct. I agree to comply with all County
ordinances ncf Stgxe ws regulating Plumbing and Sewers,
and he�eb sluthgrize representatives of this County to ente
upon t e ove-r en Ion property for inspection p poses
Igthature of. gimittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE