HomeMy Public PortalAbout9715 WINDSOR LN_Sewer__ WORKERS' COMPENSATION DECLARATION
I herebyaffirm rt t I have a certificate of consent to self
insure r ert Workers'Compensation Insurance„ or 76A642D
ry't e f (Sec. 38 ,�aa�C., - CE 808(REV.$,e,, APPLICATION FOR PERMIT
Pl11ic o "Col r 8 CPs
Certifi d copy is hereby furnished SEWER - SEWAGE DISPOSAL
•
Certified ca3py is,filed with the A unty building "spection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deprim I. t"
Date y� r 4plicant L"_¢-v„ FOR APPLICANT TO FILLIN CONNECTION DATA
ERTI CATE OF EXEMPTION FROM WORKERS' BuuowG .- STATION
COMPENSATION INSURANCE ADDREss ,. � )
(This section need not be completed if the work involved by the LOCALITY ""`�'�' MANHOLE REFERENCE
UPPER
permit is for one hundred dollars ($100)or less.) - LOWER
NEAREST '"' - TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. �`, �!�'� ". .� - Y. CURB PL. M.L.To P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. PC No.
OWNER ' .,..L-1" CO,IMP.NO, JOB NO,
MAILTRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS �� y� 1 ,
y AFFIDAVIT WANER EASEMENT RECORD,INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY Ir` -u ls� TEL
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR SI.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
tJO.OF BLDGS. PERMIT NO.
LICENSED CONTRACTORS DECLARATION slzE 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 BUsi- BUILDINGS CHARGES
ness and Professions Code and my license Is In full force and e .
effect. •�' CONTRACTOR oCONNECTION CHARGE FEE d
, 7,
License NLI! ber Lic.Class P ADDRESS REIMBURSEMENT FEE o
Contract '�-�. Date + ) DISTRICT NO. GROUP MAP PROCESSED BY u
CITY TEL„NO. -
r BK PG Z
❑ I am exempt under Sec. of the L.A.Co. CENSE NO. CLASS '� �y O
NO. DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the 'r DATE VALIDATION tu
HOUSE SEWER CONNECTING TO 9Cy DATE .....��
B. & P. Code for the fallowing reason
PUBLIC SEWER 9L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAW Z
Date. HOUSE SEWER CONNECTING TO BYr, c°
Signature CONNECT ADDSTONAL BLDG.OR
�. to _. 1.0 A
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINHED ► %` s 1 =J
I hereby affirm that I am exempt from the Contractor's License EXTN..CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, BUisneSs and Pro- ALTER,REPAIR OR ABANDON HOUSE7.
fessions Code): SEWER OR DISPOSAL SYSTEM I -r- 55 '-
❑ I,as owner of the property,or my employees with wages as v.e 27. 5 til c:-
their sole compensation, will do the work and the structure ”
is not intended or offered for sale (Section 7044, Business j % y ) ',
and Professions Code), OWNERS Permit $ d
}
❑ 1,as owner of the property, am exclusively Contracting with AUTHORIZATION TOTAL FEE
licensed contractors to COnSfrUCT the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLICONSTRUCTION LENDING AGENCY ,I hereby affirm that There is a construction lending agency SIGNED THIS DAY OF
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 Addres
I certify thatI hyave rea is application and state that the
above inform of r is c e . I agree to comply with all County
ordinances n Stateela regulating Plumbing and Sewers,
and her thor e r preseptatives of this County to enter
upon th¢ �sve- nti ed perry for inspection purposes.
Signa ure of Pe �ttee Date �t SEE REVERSE FOR EXPLANATORY LANGUAGE