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Home My Public Portal About5446 BALDWIN AVE_Sewer__ ` � 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