HomeMy Public PortalAbout9723 WINDSOR LN_Sewer__ WORKER$ OMPENSATION DECLARATION
-oilhereb efifrn t1i6t 1 have a certificate of consent to se'f
0 rt er aLp rfiftccyt f�NV k s' rr5y�erlsation Insurance, or v CE 808 D
Ar ,,�� Lib ' '' f '`EB°e`REV.B'e" APPLICATION FOR PERMIT
I�olicy No.r��Compony z� �i. `•� .�. ��.� Cis
SEWER - SEWAGE DISPOSAL
&;/Certified copy is hereby furnis ed.
Certifie0,,,'cop ,is filed with th County building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
i
epar , .. �9
Dat ' = Applicant r f"; > t<- FOR APPLICANT TO FILL 1N CONNECTION DATA
CE IFICATE OF EXEM+PrllI N FROM WORKERS' [.1
ILDING -' ! "'� o sTgnoN DEPTH
COMPENSATION INSURANCE DRESS
(This section need not be completed if the work involved by the LOCALITY'I'*,
$ / MANHOLE REFERENCE UPPER
OWER
permit is for one hundred dollars ($100)or less.) LENGTH FROM
I certifythat in the performance Of the work for which this AREST r TYPE OF CONNECTION
P OSS Scat ,y'.... A. t 14 -y. 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. ` P.C.NO`j ( -" CO.IMP.NO. JOB NO.
DateApplicantRE55 }' p J } TRUNK PERMIT NO. ROAD PERMIT NO.
-r� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO, DATE
NOTICE TO APPLICANT: If, after making this Certificate of " y
C1TW-^�""", ^►� 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 DECLARATION NO.OF BLDGS. 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 Busi- BUILDINGS " -� CHARGES
ness and Professions Code, and my License iswuli force and s
effect. � ' CONTRACT R r, - _ CONNECTION CHARGE FEE a
I
O
License Nurnber] Lic Class_ ADDRESS REIMBURSEMENT FEE
UPPP �--
COnlraCtO `'� " Daf L. DISTRICT NO. GROUP MAP PROCESSED BY Z
CITY TEL.N9. gK PG
P STATE UC. - J(
El I am exempt under Sec. of the L.A.Co. LICENSE No. CLAS s °l/ /
Plumbing Code and/or Sec. of the NO. 9!SCR66TIO0 OF JVOK FEE FINAL
HOUS SEWER CONNECTING TO --1 t:I ,� DATE %:? VALIDATION LU
PUBLIC SEWER Z
CL
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR r �� fA
PITS AND/OR DRAINFIELD F1 N.We
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, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM v a m ®,
❑ I,as owner of the property,or my employees with wages as ( 7 5their 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 $ !;� �� s 7, ` Iw, ;T'
❑ I,as owner of the property;am exclusively contracting with AUTHORIZATION TOTAL FEE L�
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
OWNERS AGENT
issued (Sec. 3097, Civ. C.).
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 and State laws regulating Plumbing and Sewers,
and hereby uthorizC re esentatives of this County to enter
upon the a v -msntia d operty for inspection purpo es.
Sig a of Perblttee Date SEE REVERSE FOR EXPLANATORY LANGUAGE