HomeMy Public PortalAbout9802 WINDSOR LN_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure,`.)r a certificate of Workers Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, L b,C. sz-000zDPwe se APPLICATION FOR PERMIT
Policy No. CVS k�'Company - of +P SEWER - SEWAGE DISPOSAL
Ele Certified copy is eby furnished.
'Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date'? C Applicorit--►Ir1l 5 1�'t i�� FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ADDRESS �� , R� STATION DEPTH
This section need not be completed ithe work involved b UPPER
( f P y the LOCALITY MANHOLE REFERENCE LOWER
permit is for one hundred dollars($100)or less.) TYPE of CONNECTION
that In the performance of the work for which this NEAREST LENGTH FROM
I certify P CROSS ST. Y. CURB. P,L. M.l TO P.I.
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. s<.
OWNER � � Die 10, CO.IMP.NO. JOB NO.
MAI
Date Applicant
ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after making this Certificate of j AFF16AVIT WAIVER EASEMENT RECORD.INSTR NO. DATE
g CITY TEL.NO. - !�� "
Exemption, you should become subject to the Workers' LEGAL tt
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. 1 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 Busl- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect: CONTRACTOR~� � CONNECTION CHARGE FEE
License Number*— fi LLiic.Class + ElnREIMBURSEMENT FEE
-�` YLL �' ADDRESS
Contract, f c �Ls ry 111 2 �' ^`•'""'0 ^�j DISTRICT NO. GROUP MAP I PROCESSED BY
�- •� CITY 1 TEL.NO.� iC r f� J,/
❑ I am exempt under Sec. [���1 Tof the L.A.Co. STATE ^� LIC. J tj BK PG
LICENSE NO. CLASS h t� 1. `f
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE _ FINAL
HOUSE SEWER CONNECTING TOj J DATE VALIDATION rr
B. $ P. Code for the following reason PUBLIC SEWER 0,2
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS ANC/OR DRAINFIELD
Date BY
HOUSE SEWER CONNECTING TO �� l
PRIVATE DISPOSAL SYSTEM _
Signature CONNECT ADDITIONAL BLDG.OR (i
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 Cade): SEWER OR DISPOSAL SYSTEM
❑ 1, as owner of the property,or my employees with wages as w
•,
their sole compensation, will do the work and the structure !7
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 47.
y
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 t
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19 ► a FStt� . ,tp
for the performance of the work for which this permit is OWNER OR
OWNERS AGENT
issued (Sec. 309 Civ. C.). ni
( ADDRESS ;+e
Lender's Name s. a
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 authorize representatives of this County to enter
upothe above-mentioned property for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE