HomeMy Public PortalAbout9727 WINDSOR LN_Sewer__ WORKERS' COMPENSATION DECLARATION
. 1 hereljy affirm that f pie,d' certificate of consent to self
insure, or a cer ificate Q046.Aers'Cgi mpensation Insuran, ao,or 76A6420
o c ;f fF�erecaf mpan80 C•, CE 808(REV.8187) APPLICATION FOR PERMIT
Pol,Y P Y 'tQ %C (Its
Certifie copy is hereby furnished. SEWER - SEWAGE DISPOSAL
iertifie copy is filed with t e'ounty buildi inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
r nt.
Da17CG'Applicant ' ' - FOR APPLICANT TO FILL IN CONNECTION DATA
E�l FICATE OF EXE TION FROM WORKERS' BUIIDINC�� y STATION DEPTH
COMPENSATION INSURANCE ADDRESS `
This section need not be completed ithe work involved b the UPPER
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p y LOCALITY _.y MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100)or less.) -
that in the performance Of the Work for which this NEARESTZZZTYPE OF CONNECTION LENGTH FROM
I certify P CROSS ST; - Y. CURB P.L. M.L.TO P1.
permit is issued, I shall not employ any person in any manner P C.NO.
so as to become subject to the Workers'Compensation LAWS. OWNER "L CO CC IMP,NO. JOB NO.
MAIL ,� TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS ��
NOTICE TO APPLICANT: If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CITY s TEL.NO. "L1
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. T HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.
I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT p}
9 (commencing with Section 7000 of Division 3 of the Busi- USE of
( g ) BUILDINGS � �' CHARGES
ne$s and Professions Code, and my license is In full force and
effect. C ^`"� 'ir^� CONTRACTO CONNECTION CHARGE FEE }
License Nt er"�s iC.Class— A,J> I ADDRESS REIMBURSEMENT FEE
COntraCTOyya` Date/� i _ CITY TEL; STRICT NO GROUP MAP ZIPROa-,
SSED BY v
-� �o' BK F'G' ,/ Z
❑ I am exempt under Sec. f the L.A.Co. LICENSE NO. CLASS ( O
r4-? 6
NO. DES RIPTI-N CfF W RK FEE v
Plumbing Code and/or Sec._ Of the FINAL
HOUSE SEWER CONNECTING TO -'r 1 DATE VALIDA ON w
PUBLIC SEWER ��
B. &,P. Cade for the following reason tn
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAtNFIELD FINA ! 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
I hereby affirm that I am exempt from the Contractor's License EXTN,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Sectors 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE d< 6
fessions Code): SEWER OR DISPOSAL SYSTEM -
❑ I,as Owner of the property,or my employee$With wages as
their sole compensation, will do the work and the structure ` a s 7 ,y
is not intended or offered for sale (Section 7044, Businessf. x
and Professions Code). OWNER'S Permit S r. ^G'y
I,as owner of the property, am exclusively contracting with AUTHORIZATION 1 TOTAL FEE i r _8
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO V
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY oil.'
I hereby affirm that there is a construction lending agency SiGNEDTHIS DAY OF 19_
for the performance of the work for which this permit is OWNiEaOncENr
issued (Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
Lender's Address
I certify that `leave read this application and state that the
above infor aOon is„ccrrec I agree to comply with all County
ordinances a d S1ct"te law re gulating Plumbing and Sewers,
and here �fautkorize re esentatives of this County to enter
upon the oV4-mentio d property for inspection purp 'es.
Si nature Of P rmittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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