HomeMy Public PortalAbout9801 WINDSOR LN_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm•that J have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof'(Sec. 3800, id�LbL�C') Y sz-oaezDPW eiee APPLICATION FOR PERMIT
NO.�! Company "i� ti-
Policy �C�" 5
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Fate-rtified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depattmem. �
Dote a Applicant C.I FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE CEXEMPTION FROM WORKERS' BUILDING C
COMPENSATION INSURANCE AODREss lq ° i` STATION DEPTH
(This section need not be completed if the work involved by.true MANHOLE REFERENCE UPPER
permit is for one hundred dnl{ars 0100)Of less.) LOCALITY LOWER
I certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
CROSS ST. ~� -, .. 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. OWNER r" P.C.NO.
CO.IMP.NO. JOB NO.
Date Applicant I TRUNK PERMIT NO. ROAD PERMIT NO.
ADDRESS `�,1
NOTICE TO APPLICANT: If, after makingthis Certificate O$ y 4 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO DATE
CITI&NIQU 0 ill TEL.NO.
Exemption, you should become subject to the WorkersLEGAL
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 is in full force and
effect. CONNECTION CHARGE FEE
CONTRACTOR q \. _�, y �.g:,a,e,q ���-e'1�
License Number91(,5._Lic.Class REIMBURSEMENT FEE
ADDRESS :'' ,$ J, ^
i-;-,
}� +�ry y DISTRICT NO. OUP MAP ('�PROCES BY
Contractor 'g .,Date . 1. .) CITY,t e' TEL.NO. G ^" y , I ! BK PG u
❑ 1 am exempt under Sec. °� _of the L.A.Co. ucENSE NO. Z Ci ss
RK F OWOFEE
DESCRIPTION
Plumbing Code and/or Sec. of the NO. FINAL •
HOUSE SEWER CONNECTING TO 71 r 1 DATE ,f VALIDATION {a-
✓ "'" e"
B. 8 P. Code for the following reason PUBLIC SEWER 2 SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD % I
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
fessions Code): SEWER OR DISPOSAL SYSTEM _
❑ 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 sole (Section 7044, Business d, -,
and Professions Code). OWNERS Permit $ L� .✓ y
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE _ w
(. i „ 5I
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 e1
I hereby affirm that (here is a construction lending agency SIGNED THIS DAY OF 19
for the performance of the work for which this permit is OWNER OR
OWNERS AGENT
issued (Sec. 3097, Civ. C.). � ,-J ADDRESS
Lender's Nome i_- 1v�,3R E Rl
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 t ,
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter +•
upon t.Kb above-menti TWdperty for inspection purposes.
z Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE j r