HomeMy Public PortalAbout9718 WINDSOR LN_Sewer__ WORKERS'COMPENSATION DECLARATION
'i hereby* aff�,ti�,4rpof
that I have a Certificate of consent to self
insure,-or Gficate of Workers'Cor spensatlon Insurance, or 76Ae42D
'� a ( @D6'Lgb C.)s�po{12,if �afoR pan s �E eoB IRE e,B,, APPLICATION FOR PERMIT
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❑yertified`copy is hereby furnished. SEWER SEWAGE DISPOSAL
rtified•copy i filed with county buil �.ng inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depart t. 9
Date ) applicant — FOR AOPLICA2T TO(fill IN CONNECTION DATA
ERTi CATE OF EXEMPTION FROM WORKERS' Buaow
COMPENSATION INSURANCE ADDRES g 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.) LOCALITY �._; LOWER
I certifythat In e performance of the work for which this NEAREST,. TYPE OF CONNECTION LENGTH FROM
fhp CROSS S; Y. CURB P.L. 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. owNEa ., CO.IMP.NO. JOB NO.
MAIL ,� TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS (�'
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. GATE
NOTICE TO APPLICANT: if, after making this Certificate of CITU•--"""''` 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 0 STATE ENCROACHMENT
NO OF BLDGS PERMIT NO.
LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOV oN LOT
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000 of Division 3 of the Busi- USE of
( g J BUILDINGS CHARGES
ness and Professions Code, and my`Xc'ense is in full force and
effect. _ yr �.} CONTRACT `J"LI w e"!`y CONNECTION CHARGE FEE
�y >
License tuber ' ic.Class / f ADDRESS REIMBURSEMENT FEE a
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rE CITY TEL N DISTRICT NO. GROUP MAP PRGCESSED BY
Contra for Date ff
❑ BK PG
1 am exempt under Sec. of the L.A.Co. LICENSE NO. .� CL SS f' E�1
Plumbing Code and/or Sec._ of the NO. WORK FEED CRI O
HNAL
HOUSE SEWER CONNECTING TO -� DATE �,r..
PUBLIC SEWER VALIDATION�'
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR kn
k`
PIT'S.AND/OR DRAINFIELD FIN z
Date HOUSE SEWER CONNECTING TO BY ,
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG,OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
1 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 HOUSE q q
fessions Code): SEWER OR DISPOSAL SYSTEM �s p, 5 A
❑ 1,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
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 AGENT
ADDRESS
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances nd State. laws regulating Plumbing and Sewers,
and hereb authori4representatives of this County to enter
upon iheoe-m tinned property for inspection purpose
I natur Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE