HomeMy Public PortalAbout9711 WINDSOR LN_Sewer__ WORKERS'COMPENSATION DECLARATION
1, hereby affirm that I have a certificate of consent to self
insure,-ot ;gepf+fl Workers'Compensation Insurance„_.f2C 76Ae42D
c fiey tFC�r�iSec. 3800, 1 � 2 a7 cG: isoa iREv.s;eli
e ) APPLICATION FOR PERMIT
alley No Company � '
Certif ed copy is hereby Turn shed. SEWER - SEWAGE DISPOSAL
ertified copy is filed with tl;e county buil g inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
departm nt.
Date 9 /P Applican FOR APPLICANT TO FILL IN CONNECTION DATA
ERT KATE OF EXEMPTION FROM WORKERS' BUILDING`.-'
COMPENSATION INSURANCE ADDRESSh7JI `, L - ;� - . STATION DEPTH
(This section need not be completed if the work involved by the MANHOLE REfERENCE UPPER
permit is for one hundred dollars ($100)or less.) Locaury Lowen
I certify that in the performance Of the work for which this NEAREST,... TYPE OF CONNECTION LENGTH FROM
CROSS ST. Y. CURB P.L. M.L.TO F.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers`Compensation Laws. JOB NO
1 P OWNERS+�fi `Z... 4 CO.IMP.NO. OB NO.
MAIL "( ` ^`y9 TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
9 CITY a 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. BDcK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION t NO.OF BLDS. PERMIT NO.
slzE of Lor Now ON Lor
I hereby affirm that I am licensed under provisions of Chapter USE of
4 commencin with Section 7000 of Division 3 of the Busi-
( g ) BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
1 C' "" CONNECTION CHARGE FEE
effect. , ,,... .--^- 4 "`�. CONrRACIO �, >.
f(_ ,O a
License Numc7�r� C..Class - _ +` 2r' ,� •' j REIMBURSEMENT FEE O
( ADDRESS c..-� �
4 L� ' DISTRICT NO. GROUP MAP PROCESSED BY
Contract r�r`A r, <= --- Date CITY TEL O.
BK PG
STATE - L4C. ) { `
❑ 1 am exempt under Sec. `of the L.A.Co.
LICENSE No, CLASS (
Plumbing Code and/or Sec.` of the OWRK FEE rs
NODESCIPTI
by
FINAL
HOUSE SEWER CONNECTING TO �{ DATE r .T �. VALIDATION a
B. & P. Code for the following reason PUBLIC SEWER t r L. e44
SEPTIC TANK,SEEPAGE PIT OR y Z
PITS AND/OR DRAINFIELD FINAL •+ G L.� 9� d A
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM 4-, •
Signature CONNECT ADDITIONAL BLDG.OR I
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ® _, fy,
I hereby affirm that I am exempt from the Contractor's License
OVERFLOW
CESS OOL DRGE IYW LL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fe5510175 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). OWNER'S Permit $ i
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATIONJ TOTAL FEE
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C NTRACTOR 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 informatio i;correct. I agree to comply with all County
ordinances and tate lawy regulating Plumbing and Sewers,
and hereby a hor,'��6 re resentatives of this County to enter
upon the ab ehntio ed prep-�tyor inspection purposes,
S 1 re of P 'mitt-- Date SEE REVERSE FOR EXPLANATORY LANGUAGE