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Home My Public Portal About4820 ARDEN DR_Sewer__ WORKERS COMPENSATION DECLARATION I hereby affirm that V, have a certificate of consent to self insure or a certificate df Workers Compensation Insurance or 76A642D i ,ro certified hRaqreof (Sec 3800LobC ) CE808(REV „831 APPLICATION FOR PERMIT Policy No ��cCompany fig � y� c�OS 4'`'f� El 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 BUILDING2 O Fri STATION R 1�(` S DEPTH 6 COMPENSATION INSURANCE ADDRESS _t (This section need not be completed if the work Involved by the LOCALITY MANHOLE REFERENCE[/iQ(� $,S Sd. O� Blit L UPPERR permit is for one hundred dollars ($100)or less ) 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 P. �r rn��" P C No 50 a5 10 become Subject 10 the Workers Compensation Laws OWNER W S l�/► /!I�AL nV/Le CO IMP No JOB NO ADDRESS (',� v`MAIL TRUNK PERMIT NO ROAD PERMIT NO Dote Applicant NOTICE TO APPLICANT If after makingthis Certificate of NO �77 AffiDAvli WAIVER EASEMENT RECORD INSTR NO DATE TEL a CITY /a r6c3 ' 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 PSTATE ERMIT NO ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO OF BLDGS ff�yJ Q/� y p ,p SIZE OF LOT NOW ON LOT IG Cr - 1329 i6 "LLQ • / 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 C. " 0 ho PS CONNECTION CHARGE FEE License Number 25-�V 9 LIC Class C -3(e ADDRESS II -- l ` REIMBURSEMENT FEE d .( SQL / 7_`�j Ztos /—` Contractor&C !S 4`(/4 t/�Date ✓ / 7 — FO CITY O/'1 r?eq C. TEL V 0 / v DISTRICT NOK GROUP BK MAP PGSTATE PROCE ED BY ❑ I am exempt under Sec of the L A Co LICENSE NO : s CLASS �U 0 Plumbing Code and/or Sec of the NO DESCRIPTION OF WOK FEE FINAL V i HOUSE SEWER CONNECTING TO DATE VALIDA N W B & P Code for the following reason PUBLIC SEWER H SEPTIC TANK SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIEID Z Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature l CONNECT ADDITIONAL BLDG OR 240 S 3 A OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT DRAINFIELD # 0 0 o C 1 0 1 hereby affirm that I am exempt from the Contractors License EXTN CESSPOOL DRYWELL MANHOLE }f Low for the following reason (Secton 7031 S Buisness and Pro ALTER REPAIR OR ABANDON HOUSE fessions Code) SEWER OR DISPOSAL SYSTEM o o27,50 ❑ I as owner of the property or my employees with wages as o 0 o27,505 their sole compensation will do the work and the structure Is not intended or offered for sale (Section 7044 Business Permit S ) Q 0 2 1 8�8 6 and Professions Code) OWNER'S (J ❑ 1 as owner of the property am exclusively contracting with AUTHORIZATIONI TOTAL FEE licensed contractors to"construct the project (Section 7044 I 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 DAY OF 19_ for the performance of the work for which this permit is OWNER OR Issued (Sec 3097 Civ C ) OWNERS AGENT ADDRESS Lender s Name 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 upo t ab jmentiopgd op ty for inspection purposes i Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORK;RS COMPENSATION DECLARATION I herebyoff]6 thaA I have a certificate of consent to self msur* or a certificote�f Workers Compensation or 76A642D is certlfled,6,ppy tFjereof (Sec 3800 Lob C )sation ILL CE808(REV 183) APPLICATION- FOR PERMIT �J Policy No Company � �C,o -p7tMg El Certified copy is hereby furnished f 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 Q STATION �!7�L� DEPTH COMPENSATION INSURANCE ADDRESS �/ (This section need not be completed if the work Involved by the .V LOCALITY i L� MANHOLE REFERENCE v 1 OWER permit is for one hundred dollars ($100)or less ) 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 TOPI. permit is issued I shall not employ any person in any manner ,//�� ` so as to become subject to the Workers Compensation Laws OWNER //f Sv CO IMP NO JOB NO MAIL t1 L TRUNK PERMIT NO ROAD PERMIT NO Date Applicant ADDRESS AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE NOTICE TO APPLICANT If after making this Certificate of CITY TEL NO �63`1)y 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 9 (commencing with Section 7000) of Division 3 of the Busl BUILDINGS CHARGES ness and Professions Code and my license is in full force and effect CONTRACTOR Z ` CONNECTION CHARGE FEE I License Number Zyg5Q LIC Class C-3 - �` REIMBURSEMENT FEE d /` Q�I ADDRESS g - Contractor)<-'e S'� / .te ` /V ^✓ 7 CITY TEL%1ji 6 3,--03/V DISTRICT NO GROUP MAP PROLE ED 8Y V STATE LIC /�'D Y BK PG ❑ I am exempt under Sec of the L A Co 09 LICENSE NO 61 CLASS v o L NO DESCRIPTION OF ORK FEE O Plumbing Code and/or Sec of the FINAL V v HOUSE SEWER CONNECTING TO GATE VALIDAT N B & F, Code for the following reason PUBLIC SEWER15- SEPTIC TANK SEEPAGE PIT OR in PITS AND/OR DRAINFIELD FINAL Z Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR , I OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER 4 0 a 2 A I hereby affirm that I am exempt from the Contractors License OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE Law for the following reason (Sectors 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE # O O O O 6 0 fessions Code) SEWER OR DISPOSAL SYS El I as owner of the property or my employees with wages as UT A 1 1.21200 their sole compensation will do the work and the structure Is not intended or offered for sale (Section 7044 Business Permit $ o 1.212005 and Professions Code) OWNER'S ElI as owner of the property am exclusively contracting with AUTHORIZATION FTOTAL FEE 06) 0 21 $—8 6 licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C NTRACTOR 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 DAY OF 19_ for the performance of the work for which this permit is OWNER OR issued (Sec 3097 Civ C ) OWNERS AGENT ADDRESS Lender s Name 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 v�n l ® b� megt�Qne pro rty for inspection purposes Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE