HomeMy Public PortalAbout9816 WINDSOR LN_Sewer__ WORKERS'COMPENSATION DECLARATION
I heiteby affirm that I have a certificate of consent to self"
insure, or a certificate of Workers'Compensation Insurance, or 7ea642D
a certified copy thereof(Sec. 3800, Lab C.) ' gz-°°°zDPW eiaa APPLICATION FOR PERMIT
Policy No ?'fel' Company r�" ir®`a.-
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. t t.
Date 1'iZ, Applicant ' t' 1'wh FOR APPLICANT TO FILL IN CONNECTION DATA.
CERTIFICATECOMPENSATIONOINSURANCEN FROM N FROM ORKERS' ADDRESS }
STATION DEPTH
( completed ithe work involved by
This section need not be com lf the UPPER
permit is for one hundred dollars($100)or less.) LOCALITY MANHOLE REFERENCE LOWER
NEAREST ?P"' TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. a Y, CURB P.L M.I.TO P,I.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws" u� rA-�.q'a^ P.C.NO.
OWNER ,v� ~` y �❑J g. CO.IMP.NO. JOB NO.
MAIL C," _ TRUNK PERMIT NO, ROAD PERMIT NO.
Date Applicant ADDRESS �,,.' ,
NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DAZE
CITY TEL NO.
Exemption, you should become subject to the Workers LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. 14 HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO,OF BLDG& 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, CONITRACTOR5i'Y(°y'"1, Y-VA-C%-�tCONNECTION CHARGE FEE
License Number LiC.CICSSS r k t+ REIMBURSEMENT FEE
.ADDRESS
Contractor �dte__- � J3 DISTRICT NO, GROUP MAP PROCESSED BY
CITY TEL.NO./-4 -�
❑ 1 am exempt under Sec. aof the L.A.Co. LICENSE NO (. CLASS'
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL r t
HOUSE SEWER CONNECTING TO DATES 1 ,j' VALIDATION
B. 8 P. Code for the following reason PUBLIC SEWER d 2 �
SEPTIC TANK,SEEPAGE PIT ORPITFJELD FINAL I---
HO E SEWER CONDRAINECT
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM 9
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER L
I hereby affirm that I am exempt from the Contractor's License - INFIELD Pilo
OVERFLOW .EEPAGDRASP DRYWMAN OLE <..
Law for the following reason (Secton 7931.5, 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 sale (Section 7044, Business
and Professions Code). OWNER'S Permit $
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE !1' 4 ;
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO i��
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. - PLE''K
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. 3179 Civ. C.). OWNERS AGENT
f
ADDRESSs
Lender's Name -' S
Lender's Address
�tnu at fiy,
I certify that I have read this application and state that the n
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
UP4 the above- ' o property for inspection purposes,
�J
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANG'ACac
' I