HomeMy Public PortalAbout9813 WINDSOR LN_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a cert4icate of Workers'Compensation Insurance, or 76ne42D
a certified copy thereof (Sec. 3800,Lob C. _ 92,0002 DPW 8/88 APPLICATION FOR PERMIT
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Policy No. t- t''.Cowpony `�'3'�'f�'.L �i� � r_k_
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
"'certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY ?,
department. -
Date Applicant) m. .f) (, r\AIF APPLICANT TO FILL IN CONNECTION DATA
TE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
CER IFIC�ACOMPENSATION INSURANCE ADDRESS c6yi
s section neenot be completed ithe work involved UPPER
permit is for one hundred dollars ($100)Or IBSS.)
(Thid ldfhb P Y the LOCALITY MANHOLE REFERENCE LOWER
LENGTH FROM
I certify that in the performance of the work for which this cCROSSTYPE OF CONNECTION
St, '
Y. CURB
P.L. M.L.TO P.L.
permit is issued, 1 shall not employ any person in any manner
P.C.NO.
so as to become subject to the Workers' Compensation LOWS. OWNER CO.IMF.NO. !OB NO.
MAIL �r,0 '""' TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS "L
NOTICE TO APPLICANT: If, after makingthis Certificate Of —• AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
CITY 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. CONTRACTOR CONNECTION CHARGE FEE
License Numbe "
!d LIC.Class 4 ADDRESS ° REIMBURSEMENT FEE
r S
��� ,�--�+ _ DISTRICT NO. GROUP MAP PROC ED BY
Contractor Date ter_, CITY TEL.NO T 11) r
{` STATELIC 1 BK PG
E] I am a empt under Sec. N� _of the L.A.Co. LICENSE N ✓ � CLAss
Plumbing Code and/or Sec. of the No. DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO DATEPUBLIC SEWER VALIDATION
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL r"
Date HOUSE SEWER CONNECTING TO BY /dLA
PRIVATE DISPOSAL SYSTEM ry
Signature CONNECT ADDITIONAL BLDG.OR �)
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ►
- --
I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE
Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE t'l
fessions Code): SEWER OR DISPOSAL SYSTEM a
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure :,�,_',_,
.(_I(
is not intended or offered for sole (Section 7044, Business , µ;•
and Professions Code). OWNER'S Permit $ J_3 C1 3 1;„
property, Y s TO10F
. . I t i
❑ I,as owner of the am exclusive) contracting with AUTHORIZATION I 1 A „34 - 50
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WIN NAMED CONTRACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTITO THE PUBLIC SEWER
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency SIGNED THIS DA19_
for the performance of the work for which this permit is OWNER OR pop.
OWNERS AGENT
issued (Sec. 3097, Civ. C.). ADDRESS a
Lender's Name , N1101-0K,I
Lender's Address 90 1 AM `.0F
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,�Teby authorize representatives of this County to enter
upor,�thereabove-mentioryedproperty for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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