HomeMy Public PortalAbout9719 WINDSOR LN_Sewer__ WORKERS'COMPENSATION DECLARATION
.I hereby of}irm that l.rhgve certificate of consent to self q�
nsur ora ertafi�n� ! rkers'CQsapensahon Insurancf, ar 'dAaa2o
a eid ,opy fir S c 3806',ab C ) CE aos!REV.Bial)
�, � Company' o p APPLICpATION FOR PERMIT
o11�yNo � / crus SEWER SEWAGE DISPOSAL
ertifled copy is hereby furnished. �7
ertifled opy filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
d part ,Jnt; s
Date �a' t Applica it y j� - FOR APPLICANT TO FILL IN CONNECTION DATA
CER FICATE OF EXEMPTION FROM WORKERS' Bu1LDIN ''is`"
COMPENSATION INSURANCE ADDRESS$ fit;' STATION DEPTH
(This section need not be completed if the work involved by the UPPER
LOCALITY i' MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100)or less.)
I certifythat in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
e p CROSS ST. Y. CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner P.c.NG.
so as to become subject to the Workers'Compensation Laws. OWNS
r`"�`;•`y�„'3-�* -"i....,..... ( s CO.IMP.NO. JOB NO.
MAIL
�'�,r � - �'''�" �+,,. TRUNK PERMIT NO. ROAD PERMIT NO.
Date-Applicant (-.-�
NOTICE TO APPLICANT: If, after makin this Certificate of ) - d AFFIDAVIT WAIVER EASEMENT RECORD.INSiR NQ DATE
g CITI'^'—'� Y y. �✓1.--.y TEL.NO
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION OT No. `'
HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed / 3
revoked. BLOCK TRACT 6 ( STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT No.
I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE OF ?
9 (commencing with Section 7000) of Division 3 of the Busi BUILDINGSCHARGES
ness and Professions Code, and y I,cense is in full force and
effect. PCONTRACTp y-: . 4'- �,. CONNECTION CHARGE FEE
License uA Jf
4er _Lic.Class �y ADDRESS REIMBURSEMENT FEE CL
s V
;t. ., s ..;� DISTRICT NO. GROUP,.:. MAP PROCESSED BY
COPtfOCT �-- Date CITY TEL.NO. � " BK PG Z
STATE -'a-.. �_._.. LI
❑ I am exempt under Sec. f the L.A.Co. LICENSE NO. CLASS p f { O
Plumbing Code and/or Sec. of the NO,,t DE90RIPTIONIOrWORK FEE
FINAL r
HOUSE SEWER CONNECTING TODATE PUBLIC SEWER * VALIDATION a,
{r _ .✓r
B. & P. Code for the fallowing reason �l- FIN Y a V7
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO B
PRIVATE DISPOSAL SYSTEM '
Signature �y Cl
g - CONNECT ADDITIONAL BLDG.OR o► ..
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 *y
fessions Code): SEWER OR DISPOSAL SYSTEM to
❑ 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, 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 info,"04116n is correct. I agree to comply with all County
ordinance on,d State 1`6regulating Plumbing and Sewers,
and hery ctu)lh'rize r resentatives of this County to enter
upon th abo re-mentlg'ned property for inspection pur{iose..'
J l
$nature of mit tee Dare %' SEE REVERSE FOR EXPLANATORY LANGUAGE