HomeMy Public PortalAbout9810 WINDSOR LN_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a wrtificate of Workers'Compensation Insurance, o: 7RA642D
a certified copy thereof(See. 3800,19§,C.) Q 92-MO2DPW 6/59 APPLICATION FOR PERMIT
Policy No.( �,op`vyli, .reby
Company * ai3 )4` SEWER - SEWAGE DISPOSAL
❑ C tified furnished. `g
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY I
department. F t _ )
Date Applicant, I l( f I i FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXE ON FROM WORKERS' BUILDING �' ^ ` : STATION DEPTH
COMPENSATION INSURANCE ADDRESS { F u20(L
(This section need not be completed if the work involved by the. MANHOLEREFERENCE UPPER
LOCALITY LOWER
permit is for one hundred dollars ($100)or less.) LENGTH FROM
NEAREST TYPE OF CONNECTION
I certify that in the performance of the work for which this CROSS ST. � Y. CURB P.I. MA TO P.L.
permit is issued, I shall not employ any person in any manner +�f
so as to become subject to the Workers'Compensation Laws. OWNER p�jvf0-6 CO.IMP.NO. JOB NO
Date—Applicant ADDRESSMAIL —1lJC} � ��J TRUNK PERMIT NO ROAD PERMIT NO.
NOTICE TO APPLICANT: if, after makingthis Certificate O{ ^^ `Zj AFFIDAVIT WAIVER EASEMENT RECORD.INSTR NO. DATE
CITY p TEL.NO. "�,�
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. I 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 N°.
SIZE OF LOT NOW ON LOT
1 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. CONTRACTOR p�y,.�' i F i IV 1 CONNECTION CHARGE FEE
License Number 1 2(k Lic.ClassA ADDRESS46-22 REIMBURSEMENT FEE
Contractor f{7af@ ^� --t-„ ,/�. DISTRICT NO. GROUP MAP PROCESSED BY
. C10 CITY s E o TEL.NO. "'C _ r
--77 -�g BK PG
J I am @ mpt Under Sec._. _._Of the L.A.CO. LICENNO,
SE
LCLASS
Plumbing Code and%or Sec. of the NO DESCRIPTION OF WORK FEE FINAL 111 fff
HOUSE SEWER CONNECTING TO - ( LLf DATE � �'? ..i�f� VA (DATION
PUBLIC SEWER
l G
B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL
O
PITS AND/OR DRAINFIELD ,yam _
Date HOUSE SEWER CONNECTING TO BY 7 /Jr �9” (}
PRIVATE DISPOSAL SYSTEM Cs 6
Signature CONNECT ADDITIONAL BLDG.OR "
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER �7
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 (Sector 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE ,?
{ession5 Code): SEWER OR DISPOSAL SYSTEM
JL
❑ I,as owner of the property,or my employees with wages as4`''
their sole compensation, will do the work and the structure
is not intended or offered for sole (Section 7044, Business
and Professions Code). OWNER'S Permit $ ( s i I L _
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE `I/I ) '.�� �„¢ � erR
licensed contractors to construct the project (Section 7044, 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. �"^• ,-,
CHECK
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 OR
issued (Sec. 309 iv. C.). j�5! e y jk OWNERS AGENT »�
Lender's Name' D ill°F.f & Gt ADDRESSIs 1.CC
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, I..
and,.hereby authorize representatives of this County to enter a
Ae above-rnentifllaed property for inspectian purposes.
ature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE