HomeMy Public PortalAbout9712 WINDSOR LN_Sewer__ WORKERS'COMPENSATION DECLARATION
h hereby.ciffirm that I have a certificate of consent to self
ins or r+lifiCate of Workers'Compensation insurance, or 76A642D
oy No. hreoCosmpan8 � I �„ ro, OPsB°8`REV8/81) APPLICATION FOR PERMIT
erlified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
N-Cerlified cop is filed with the county buildi inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
de p.rr.
ent.
Date pplied � 'J `+ FOR APPLICA T TO FILA IN CONNECTION DATA
%CER�FIC�A�TEA
OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRES + .
(This section need not be completed if the work involved by theUPPER
LocnuTY 4 _ MANHOLE REFERENCE LOWER
is for one hundred dollars ($100)or less,)
that In the performance of the work for which this NEAREST ^�` TYPE OF CONNECTION LENGTH FROM.
I certify P CROSS T. Y. CURB P,I. M.L TO P.I.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. e P.C.NO.
OWNER -1 - .,," O" CO-IMP.NO. JOB NO.
MAIL
TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
NOTICE TO APPLICANT If, after makingthis Certificate Of �rJ ''7' 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 DECLARATIONNo.of aLOGs. 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 BUST- BUILDINGS CHARGES
ness and Professions Code, and mv.license is in full force and
effect. '' ''` ' CONTRACTOR �.,„E.. �'-J CONNECTION CHARGE FEE
A`
License Number Lic.Class f
C.
:. .ADDRESS REIMBURSEMENT FEE
r.
Contrac or 'D%J-- �-- DatA"(- Z44 DISTRICT NO GROUP MAP PROCESSED BY
CITY TEL.NO,. ` -C v BK PG
STATE LIC. - F�I ��
❑ I am exempt under Sec. of the L.A.Co. LICENse NOK VL CLASS
.': 0
Plumbing Code and/or Sec. of the NO DSC PTI OF O FEE FINAL - p U
LU
1^� a
HOUSE SEWER CONNECTING TO DATE L.f �--" VALIDATION
B. & P. Code for the following reason PUBLIC SEWER ,.�� a
SEPTIC TANK,SEEPAGE PIT OR - z
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ,
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN„CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, BUlsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM ': tf-, .Y 1, A
❑ 1,as owner of the property,or my employees with wages as r
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business Permit ` 1 �.s r �: <)
and Professions Code). OWNERS $ `
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE
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
sued (Sec. 3097, Civ. C.). OWNERS AGENTADDRESS
Lender's Name
Lender's Address_
I certify that I have ead this application and state that the
above information ' forrec lee to comply with all County
ordinances and qte la s r gulating. Plumbing and Sewers,
and hereby au�rize epr entatives of this County to enter
upon theabov 'menneyf property for inspection pur-ose;.
Si ator of Per el
ee Date g. SEE REVERSE FOR EXPLANATORY LANGUAGE