HomeMy Public PortalAbout5446 BALDWIN AVE_Sewer__ (2) ` � N
r WORKERS COMPENSATION DECLARATION
I hreFy jffym that I have a certificate of consent to self 11
e ir�sura or a certificate of Workers Compensation Insurance or �sAea20 U
a certified copy thereof (Sec 3800 Lab C , CEBOB(REV 1/83) APPLICATION FOR PERMIT
Policy No Company
❑ 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 - FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING / STATION DEPTH
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the //27 REFERENCE UPPER
permit is for one hundred dollars ($100)or less , LOCALITY GG LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify-that in the performance of the work for which this CROSS ST / Y CURB P L ML TOP L
permit is issued I shall not employ any person in any manner PC NO
so as to become subject to the Workers Compensation Laws OWNER CO/ CO IMP NO JOB NO
MAILDate'1�7��Applico � ADDRESS /til/I/ L TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT If after m ng th Cer fi Of CITY SCG /� TEL NO AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
Exemption you should become bled o th 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 ENCROAACHMENT
i PERMIT NO �S
LICENSED CONTRACTORS DECLARATION' SIZE OF LOT -G— G NOW ONLLOTs CS &,m
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 J�l�lG /��sf CHARGES
ness and Professions Code and my license is in full force and
effect CONTRACTOR Ate/ CONNECTION CHARGE FEE
License Number Lic ClassADDRESS �/y/� REIMBURSEMENT FEE '.
i DISTRICT NO GROUP MAP P OCESSED BY d.
Contra Cf Or Date
CITY TEL NO - (/ `n BK PG V
❑ I am exempt under Sec of the L A Co LICENSE NO ���8�STATE CLASS or J(
` '` a
NO DESCRIPTION OF WORK FEE O
PlumbingCode and/or Sec of the FINAL
HOUSE SEWER CONNECTING TO DATE �( VALIDATION u
B & P Code for the following reason PUBLIC SEWER
W
SEPTIC TANK SEEPAGE PIT OR FINAL A.
PITS AND/OR DRAINFIELD N
Date HOUSE SEWER CONNECTING TO BY Z
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG OR
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER
IELD
I hereby affirm that I am exempt from the Contractor s License EOXTNFLo SEEPAGE PLDR WELL N^AFNHOLE ;2 4 A
Low for the following reason (Sectors 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE # e 0 0 0
fessions Code) SEWER OR DISPOSAL SYSTEM
l0 54
❑ I as owner of the property or my employees with wages as i�
their sole compensation will do the work and the structure o o ' 2 7 5 4 50
is not intended or offered for sale (Section 7044 Business
onclyrofessions Code) OWNER S Permit $ 111
E;-<.S owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE a2 2 2'$b
licensed contractors to construct the project (Section 7044 1 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
CONSTRUCTION LENDING AGENCY
I herebyaffirm that there is a construction lendingagency SIGNED THIS AY OF 9
for the performance of the work for which this permit is OWNER OR ` P111110, ';24515A
Issued (Sec 3097 Civ C ) OWNERS AGENT
n
# o o s o 1 0
�A ADDRESS
Lender s home �/�Y/�G��9.t1 G7�
Lender s Address —�TL� lic/ i�S!/�� /— L/1� 1 - 2750
1 certify that I have read this application and state that the e o s 2 7 5 0 5
above information is correct I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers 04,22—, 86
and hereby authorize representatives of this County to enter
upon the above mentioned property for inspection purposes
Signature o rmitte Da SEE REVERSE FOR EXPLANATORY LANGUAGE
' WORKERS COMPENSATION DECLARATION
I hereby �afftrm that I have a certificate of consent to self �I
Insure or a certificate of Workers Compensation Insurance or CE 808D
a certified copy thereof (Sec 3800 Lab C ) sae(REV lied APPLICATION FOR PERMIT
Policy No Company
Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
El
❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS fNEAREST
DING ��/ ,r/ w/ /a
COMPENSATION INSURANCE RESS J �1�Y �L [�f�</sr C� STATION D :� DEPTH
(This section need not be completed If the work Involved by the ��� L� Gf f' MANHOLE REFERENCE 7d UPPER
permit is for one hundred dollars ($100)or less ) ALITY LOWER
TYPE OF CONNECTION LENGTH FROM
I certify that In the performance of the work for which this SS ST //Y�s Y CURB P L ML TOPIL
permit Is Issued I shall not employ any person In any manner
PC NO
so as to become subject to the Workers Compensation Laws OWNER
CO IMP NO JOB NO s
' MAIL //T Z'� �t � TRUNK PERMIT NO ROAD PERMIT NO
Date Appllca I-1 ADDRESS �T / �^�V
NOTICE TO APPLICANT If after Ing t S C tI to Of CITY iGc/sc!/ TEL NO F�J�+��� AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
Exemption you should become subject to the Workers LEGAL
Compensation provisions of the Labor code you must forthwith DESCRIPTION LOT NO IRE
ST WIDENING
comply with such provisions or this permit shall be deemed
revoked j BLOCK TRACT CROACHME T
LICENSED CONTRACTORS DECLARATION NO OF BLDGS O
SIZE OF LOT 7d NOW ON LOT dSIS-,,34,j 57/
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busl BUILDINGS «�� �s�/ CHARGES
ness and ProfpsslOns Code and my license is in full force and
effect CONTRACTOR Lam. SfL�� ION CHARGE FEE
License Number LIC CIOSS ADDRESS �/Q � EMENT FEE
Contractor Date CITY TEL NO NO GROUP MAP PROCE ED BY V
I { BK PG
❑ I am exempt under Sec of the L A Co LICENSE NO SSTATE �c �e' ciASS — _ O
Plumbing Code and/Or Sec of The NO DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO ® ,O VALIDATION WB d P Code for the following reason PUBLIC SEWER SEPTIC TANK SEEPAGE PI7 OR
PITS AND/OR DRAINFIELD Z
Date HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM YJ 4f
Signature CONNECT ADDITIONAL BLDG OR 9451 3 A
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT DRAINFIELD I1 5 O
I hereby affirm that I am exempt from the Contractors License EXTN CESSPOOL DRYWELL MANHOLE
Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE
fessions Code) SEWER OR DISPOSAL SYSTEM p o 1 5 4,O O U
❑ I as owner of the property or my employees with wages as L ~ _
their sole compensation will do the work and the structure 0 a 2 2—8 6
I not Intended or offered for sale (Section 7044 Business Permit $
and Professions Code) OWNER S
I as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE
licensed contractors to construct the project (Section 7044 1 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
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency SIGNED THIS �Z"DAYOF 19 }
for the performance of the work for which this permit Is OWNER OR eft
P P OWNERS AGE
Issued (Sec 3097 Civ C )
�� ADDRESS
Lender s Nome
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 the above mentioned property for Inspe Ion/purposZs �/
Slgnatur Per Itte Date SEE REVERSE FOR EXPLANATORY LANGUAGE