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Home My Public Portal About9144 BROADWAY_Sewer__ WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate.of Workers'Compensation Insurance, or ]6A0<40 P der mos ` -1mpany `sj CE see e'BI' APPLICATION FOR PERMIT rl ❑ I led copy is hereby furnished. _ SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building ins ecton ' t COUNTY OF LOS ANGELES BUILDING AND SAFETY ' Da;0Ap7ilicant ' `^� FOR-APPLICANT-TO FILL-IN CONNECTION DATA F' RTIFICAFE/OF EXEMPTION FROM WORKERS' BUILMN COMPENSATION INSURANCE ADDRES .TION - DEPTH --(This section:need:not.be completed if.the work.involved by the UPPER . _. . LOCALIT / _- -cam ��_ _.�__.�_ MANHOLE REFERENCE permittis forone hundred dollars ($I00)or less.) :"•` -�"_'- --- - - -- -�-' = - �- _ ._ � LowER NEAREST - I certify that the pTYPE LENGTH FROM erformance of the work for which this CROSS Si. Y: CURB P.L M.L.TO RL. Permit is issued, I shall not employ any person in any manner so as to,become subject to the Workers'Compensation Laws. P.C,NO.,, O R CO.IMP.N JOB NO. ADL sTRUNK' RAT NO, ROAD PERMIT NO. Date - Applicant MAIL _ NOTICE TO 'APPLICANT If, after making this.Certificate Of ,r nJHWY. AFFIDAV WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY Exemption, you should become subject -to the Workers' LEGAL . Compensation provisions of the Labor code, you must forthwith DESCRIPTION' LOT NO. OR Bi.WI INGcomply with such provisions or this-permit shall be deemed - "revoked. - eLocK TRACT TE ENCROACH E TLICENSED CONTRACTORS DECLARATION NO.OF BLDG MIT NO.512E OF LOT NOw ONt0I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of.Division 3of the Busi- ewmw C' CHARGES ness and Professions Code, and my license is in full force andeffect — CONTRALTO N CTION CHARGE FEE Y' d LiCenSdEiC.Class �''� gDDRE RE E O C tE _ -� DISTRICT O. GROUP MAP PROCESSED BY V ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO.TATE a �.� + ( BK w Z Plumbing Code and/or Sec. of the NO. DESCRIPTION WORK HE FINAL A-3 ( _ \ HOUSE SEWER CONNECT GTO DATE VALIDA N W B. 8 P. Code for the following reason - PUBHC SEWER H SEPTIC TANK.SEEPAGE PIT R PITS AND/OR DRAINFIELD BY Z Do PR VATI DISUSE POSAALL CONNECTING O BY +r) 5lgnaf NNECT ADDITIONAL BLDG. R - - It i WORK i0 HOUSE SEWER OWNER-BUILD DECLARATION - Al:l'Ta OVERROW SEEPAGE PIT,DRAIN ELD , SJ�� 1��i�1 I.hereby affirm that I am ex mpt from the Contractor's License Exirv., ESSPOOI,DRvwEL1.MA HOLE Law for-the fallowing reason (Secton 7031.5, Buisness and Pro- ALTER,RE R OR ABANDON HO 5E ' fessions Code): SEWER OR D SAL SYSTEM ITEM E ' ❑ I,as owner of theproperty,or my employees with wages asTOTAL Lr i 1Q their sole compensation, will do the work and the structure 1_J - is not intended or offered for sale (Section 7044, Business - 21,`O and Professions Code). OWNER'S ,Permit g CHECK " property, v g TOTAL FEE CHANGE •Ctrl ❑ I, as owner of .am exclusive) contracting with AUTHORIZATION licensed contractors to construct the project (Section 7044, HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR i0 Business and Professions Code). . . CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY - - t l�I�OO-ODDS 1/ 4/89 1 hereby affirm that there is a Construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which thisP ermit i5 OWNER OR, issued (Sec. 3097, Civ. C.). OWNERS AGENT Lenders Name ADDRESS . lender's Address - -- T - I certify that.) 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 h eb ize representatives of is County to enter - + upo a/ave-me tionedd �rfy for i spection ureases.. Signature of Per ittee P6te /� SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION "I hereby affirm-that I have a certificate of consent to self _ insure, or a certificate of Workers'Compensation Insurance, or 76AM2D a certified copy thereof(Sec. 3800, Lab C.) CE 808(REV.8/81) APPLICATIONPolicy No. ompany es C ®R PERMIT C ❑.Certified copy is hereby furnished. - SEWER - SEWAGE DISPOSAL , ❑ Cer Pied c py is filed with the county building in pection COUNTY OF LOS ANGELES BUILDING AND SAFETY DateP rt pplicant A 1111=2I FOR APPLICANT TO FILL IN CONNECTION DATA ERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY LOWER I certify that in the performance of the work for which this NEARESTTYPE OF CONNECTION LENGTH FROM permit is issued, I shall not employ an person in any nner CROSS ST Y. CURB P.L. M.L.TO P.L. so as fo eco( co sub' ct to the Work 'Coriratio aws. P.C.NO. OWNER / CO.IMP.NO. JOB NO, MAIL Applica MAILADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. Dote NOTICE O A LICANT: If, after making this CE If Kate Of CITY L NO 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. HWY.OR Si.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATIONNo.of BLLODGs. q_ PERMIT NO. SIZE OF LOT NOW ON T 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 license is in full force nd effect. 77 CONTRACTOR A a' CONNECTION CHARGE FEE } License NUmbe .Class ADDRESS ' REIMBURSEMENT FEE 0 Contractor ate D15iRlCi NO. GROUP MAP PROCESSES BY V CITY STATE •� BK PG 7- ❑ I am exempt under Sec. of the L .C . LICENSE NO. CLAS ,� L K. O Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL ��/1111 F- 'HOUSE SEWERPUBIIC SEWR CONNECTING i0 DATE VALIDA W E B. 8 P. Code for the following reason N Z $EPs TANK,SEEPAGE PIT OR PIT AND/OR DRAINFIELD FINAL _ Date U$E SEWER CONNECTING TO RIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR D , OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER hereby affirm that I Om exempt from the Contractor's License - OVERFLOW CESSPOOL.DRYMILILAMANHOLE Law for the following reoson-(Secton 7031.$, BuiSness and Pro. ALTER,REPAIR OR ABANDON HOUSE fessions Code): I SEWER OR DISPOSAL SYSTEM ❑ 1, 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 and Professions Code). OWNERS Permit g ❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE , licensed contractors to construct the project (Section 7044, HAVE AT THIS DAi A CONTR Ci W iH HEREIN NAMED CONTRACTOR TO 10 Business and Professions Code). CONNECT THE ABOVE ESCRIBET DW LING iO NAMED SEWER.' -- - - - CONSTRUCTION-LENDING,AGENCY__. I .hereby affirm that there is a construction lending agency- SIGNEDTHIS' I F --- 7 e for the performance of the work for which this permit Is OWNER OR D — -- _ - - 3,137 - _ - — 1.50 issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDREs =44V WAY 1 ITEMS Lender's Name }I13 AL ,# -_c0 TICITA Lender's Address �1 �jl I certify that I have read this application and state that t CASH above inform n is correct. I agree to cam with all C nt 4 1 g comply v {-HANGE Oher State laws r Plumbing an ewers, uthorize.representativ of his Co y to enter ve-mentioned pr for i spe IT Ur 1,2 13116+ 1 AM 9:131 gnature of Perortlee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE