HomeMy Public PortalAbout9807 WINDSOR LN_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby offirs`ti that 1 have a certificate of consent to self
insure,'or a certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800 ab C.) 92-0002 DPW 6/88 APPLICATION FOR PERMIT
Policy No. DISI54-KICompony
❑ certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL
Ceriified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportmeni. ���
Date 2 �_Applicant ri 9 r11,1 �1, ('� � ? FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING 4 i STATION DEPTH
COMPENSATION INSURANCE ADDREss �
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit it for one hundred dollars ($100)or less.) LOCALITY LOWER
NEAREST TYPEOF CONN€CTION LENGTH FROM
I certify that in the performance of the work for which this ceoss sT. a Y CURB P L M L TOP t
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 CO.IMP NO, JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date--.Appl ica nt ADDRESS L!�` 1s +L,°
AFFIDAVIT I WAIVER FASEMENT RECORD.INSTR.NO, DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY �{ a' 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 is in full force and
effect. pyo! CONTRACTOR ' (` CONNECTION CHARGE FEF
License Number L�ry 6011 Lic.Class ' ` ADDRESS REIMBURSEMENT FEE
1 1
DISTRICT NO. GROUP MAP {., PROCu"D BY
Contraetof.�'�Il�i Date ���� w e
�++, CITY TEL,.NO. r) BK PG } + y
❑ CL
I am exempt under Sec. —of the L.A.Co. STATE 5 classy
P LICENSE NO.
Plumbing Code and/or Sec.J of the NO. DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO y - DATE VALIDATION
B. & P. Cade for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR
FINALI
Dare PITS AND/OR DRAINFIELD rJ
-- HOUSE SEWER CONNECTING TO Ld
PRIVATE DISPOSAL SYSTEM CL
Signature CONNECT ADDITIONAL BLDG.OR i {•/)
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEfPAGE 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 Cade). SEWER OR DISPOSAL SYSTEM .. -
❑ 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 $ j 51
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION rTOTAL FEE34 _ 50
licensed contractors to construct the project (Section 7044, 1 HAVE Ar THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO -
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. rw v "yls. :ZrI
CONSTRUCTION LENDING AGENCY tar Yr';
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 a
j� > ADDRESS.
Lender's Name -^`
Lender's Address
sZ'.,: 4. 3-1a
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
upon tie above-menPianecT property for inspection purposes.
Signature of Permittee a Date SEE REVERSE FOR EXPLANATORY LANGUAGE