HomeMy Public PortalAbout9708 WINDSOR LN_Sewer__ „` WORKERS'COMPENSATION DECLARATION
I here'fy affirm that I have a certificate of consent to self
insure,p.r a ce !%ompan
tWorkers'C ensation Insura XQg _Dr %aAea2D
rii..t ,opySec. 3 7 _b�.)Y °, -CEBD8(REV.B/B1) APPLICATION FOR PERMIT
y�No. y �,..... f� f GS
ertifie�copy is hereby furnished. SEWER - SEWAGE DISPOSAL
9cc,ertif'4d c y is filed with.1he county buitJc
ng Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
e h
Date 4.1 �� ApplicantL' `”
FOR APPLICANT TO FILL ,N CONNECTION DATA
CE TIFICATE OF EXEMPTION FROM WORKERS' BUILDINGs. �":COMPENSATION INSURANCE srnnoN DEPTH
This section need not be com leted if the work involved b the UPPER
( p yMANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100) or less.) TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this YcuRe P,L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner Pc No.
so as to become subject to the Workers'Compensation Laws. co.IMP.No. �oB No.
1'`N` '` TRUNK PERMIT NO. ROAD PERMIT NO.
DateApplicant —<-
NOTICE TO APPLICANT: If, after making this Certificate of clTv TEL.NO. � aAFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
` ',�
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
c NO.OF BLDGS. PERMIT NO.
LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF I' ?
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS I � CHARGES
ness and Professions Code, and myicense Is in full force and
effect. ��'' , am.+' -'� -, CONNECTION CHARGE FEE r
,.�"-�� CONTRACTOR
License Number Lic.Class - ADDRESS REIMBURSEMENT FEE 0
.....-
�,.. DISTRICT NO. GROUP MAP PROCESSED BY o
COntractor �pDate CITY E O. BK PG Z
STATE - LIC. - -.+
❑ !am exempt under Sec. It—
of the L.A.Co. ICENSE No a CLASS r. l`�`�
NO. Q SCRI TIO O WORK FEE V
Plumbing Code and/or Sec._ _of the FINALq
HOUSE SEWER CONNECTING TO W
B. & P. Code for the following reason PUBLIC SEWER y $ DAT VALIDATION Z
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINHELD FINA ,' z
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM Z � t 3 A
Signature CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER
OWNER-BUILDER DECLARATION # a 1
I hereby affirm that I am exempt from the Contractor's License EEXTN.,CESSPOOL'SEEPAGE PIT, MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE E j f,8
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
and Professions Code). OWNERS Permit $ ,
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE "� C
licensed contractors to Construct the project (Section 7044, I 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 AGENT
ADDRESS
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above Informati s correct: agree to comply with all County
ordinances an State.Idws; eguloting Plumbing and Sewers,
and hereby thorVt re esentativeS of this County to enter
upon thea Je-mt�ntio d p "perty for inspection purposes.
SIg dture of P ittee Date SEE REVERSE FOR EXPLANATORY'LANGUAGE