HomeMy Public PortalAbout9821 WINDSOR LN_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
inure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof Sec. 3800, Lab C. 92-0002 DPW 6/88
Policy No.1 Company !!E +1 S 'inr _ APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
❑ Ce led copy Is ereby furnished.
Certified copy is filed with the county building inspection. COUNTY OF LOS ANGELES BUILDING AND SAFETY i.
de a tmeni
Date. Applicantl_ ad fy�cd l9 V1fAl FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATEEXEMPTION WORKERS' RSS STATION DEPTH
COMPENSATION INSURANCE ADDE `
(This section need not be completed if the work involved by the UPPER
LOCALITY MANHOLE REFERENCE 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.L. M L TO P.L.
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 r TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS ` r
AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY ifs 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 NOOF BLDGS. PERMIT NO.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 y , n al CONNECTION CHARGE FEE
License Number, lib Lic.Classy ADDRESS '� 1. L w REIMBURSEMENT FEE
iyiy�.. 0ma �a1L+ t. �'--` //��,.y DISTRICT NO. GROUP MAP ?„�,,PROCE D BY
CQntractOf, +_ CITY TEL. ` f�1 ZI 1,.� '7 BK PG �#')� r
❑ 1 am exempt under Sec. 1 ti—) 1- -of the L.A.Co. LICENSE NO. e�!" CLASS �, 0-
Plumbing Code and/or Sec. of the No. DESCRIPTION OF WORK FEE _ FINAL —'
HOUSE SEWER CONNECTING TO f "� DATE VALIDATION Of
PUBLIC SEWER
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
—Date 8Y
HOUSE SEWER CONNECTING TO 6111
PRIVATE DISPOSAL SYSTEM a-
Signature CONNECT ADDITIONAL BLDG OR J
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
❑ 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 z EMS
and Professions Code). OWNERS Permit $ (� _ _
El1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE s L O AL 4 .50
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED „ NTRACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY
t,' 't31
1 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
OWNERS AGENT
issued Sec. 309 Civ. C. n ADDRESS �'�(,3,J : t 'L
L? ;=
Lender's Name - , K,
Lender's Address AM ?:C5
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
up the above-mentgsTe�d property for inspection purposes.
S gnature of Permittee Date ! ,-�-- SEE REVERSE FOR EXPLANATORY LANGUAGE
f