HomeMy Public PortalAbout9822 WINDSOR LN_Sewer__ WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have o certificate of consent to self
insure,or d certificate of Workers'Compensation Insurance, or 76ArA2D
a certified copy thereof (Sec. 3800 �°�bC.) sz-000.DPW siss APPLICATION FOR PERMIT
Policy Nc Company e
❑��Certified copy is ereby furnished. dem' SEWER - SEWAGE DISPOSAL
Ii C=ertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
departm nt.
Date 1�Z_App"cant- ) ` l FOR APPLICANT TO FILL IN CONNECTION DATA
CER IFICATE OF EXEM ON FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS lis STATION DEPTH
(This section need not be completed J 1he Work Involved by t'ie MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($700)or less.) LOCALITY _ LOWER
certifythat in 11'1@ f NEAREST (" TYPE OF CONNECTION LENGTH FROM
performance of the work for which this CROSS ST. T„J1 L Y. CURB P.I. M L TO P.L.
permit is issued, I shall not employ any person in any manner P.0 No,
so as to become subject to the Workers'Compensation Laws.
OWNER CO.IMP,NO JOB NO.
MAIL
Date Applicant ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after makingthis Certificate of �- (( AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CITYJ�M 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
4 (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. (4 CONTRACTOR t CONNECTION CHARGE FEE
License Number _Lic.Class n ADDRESS �- REIMBURSEMENT FEE
Contracto Date C� It DISTRICT NO. COUP MAP PROCESS BY
�. iy` --C?P�,—� CITY TEL NO. L� ,.
❑ I am exempt under Sec. D of-the L.A.Co. LICENSE NO. nr' class ( 3 BK PG ( jCL
Plumbing Code and/or Sec. of the NO DE CRIPTION OF WORK FEE FINAL (\ Pf++f `}
PUOBL USE C SEWER SEWER CONNECTING TO `Y FI; DATE•�.�j Z >"�f VALIDATION tr_
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR CONNECTING
ONN
CON
Dare HOUSE SEWER NECTIECTI FINAL
NG TO BY
PRIVATE DISPOSAL SYSTEM `Z1
Signature CONNECT ADDITIONAL BLDG.OR
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
feSSlons Code): SEWER OR DISPOSAL SYSTEM
�❑ Is
I i 9 I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure <: � t
is not intended or offered for sale (Section 7044, Business
and Professions Code), OWNERPermit S $4: o f I
❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATION FTOTAL FEE e
licensed contractors to Construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO tt i!I ^a.d
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER, 4'
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency OR SIGNED THIS DAY OF 19_ ; (
for the performance of the work for which this permit is OWNVER AGENT
issued (Sec. 3047 Civ. C.).
Lender's Name 1 ` ADDRESS
j, ,1
? D,"
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,
and hereby authorize representatives of this County to enter
upon.tbe above-tnenti_Qlleef property for inspection purposes.
Signature of Permittee Date
SEE REVERSE FOR EXPLANATORY LANGUAGE
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