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Home My Public Portal About9435, 9437, 9441 BROADWAY_Sewer__ WIDRKERS' COMPENSATION DECLARATION Fiereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance or 6AeE2D A� /LT a certified cQ th/ere f (Sec:'38001 b G. - _ 'cE eoatREv,B/Btt APPLICATION ION' FOR PERMIT Policy No..O (7ytompanyf�1 ZuJQ'�f d,v Os ❑ Certified copy Is hereby fu-mished. °x• "C�l _ SEWER - SEWAGE DISPOSAL Cort�fled copy is filed with,the coun(y buildQing'9i�nspection COUNTY OF LOS ANGELES BUILDING AND SAFETY': Date Applicant W I u-I Aw+ O'>. yE•)Fl� t, y - FOR APPLICANT TO FILL IN - CONNECTION DATA CERTIFICATE OF.EXEMPTION FROM WORKERS' BwmtNG 9r COMPENSATION INSURANCE - • ADDRESS. yJ '.Q srnnoN .�-/s, 7 DEPTH (This section need not be completed if the'work:invBlved by the ` •gip MANHOLE REFERENCE UPPER permit Is;for;one-hundred dollars ($100)or less.) r LOCALITY -./ `µw G- ,. -`�' •' +' .LOWER / - "ArDDRESSt-' TYPE OF CONNECTION 't£NGTH FROM I"certify that in the performance;of`the work•for which this �/ - v! - cuae P.L. LEN TO P.L. permit is issued, I shall'Dot:empIcI person In"any manner. - - Pc.No so,as to become.sublect to the'Workers'Compensation Laws. (,✓ yI/.,(,d L, Cit:IMP.No. - LOB No. -FTRUNK'PERMIT NO. ROAD PERMIT NODate Applicant K ✓z1�NOTICE 10 APPLICANT: If, after making thl5 CErhflCat2 Of A TEL N .�' 7�,� / AFFIDAVIT.. WAIVER EASEMENT RECORD!INSTR.:NO, DATE. _ _ Exemption, you should become subject to', the Workers' Compensation rovisions of the Labor code, you must forthwith LEGAL P P Y DESCRIPTION LOT NO. comply with such provisions or this permit shall be deemed I - - - / _ HWY.OR ST.WIDENING. revoked � - BLOCK - _TRACT -Q 5 TE C AC E T -LICENSED CONTRACTORS DECLARATION' ' • No.OF BLDGS �ti ��, P ER TG SIZE OF IOi - NOW ON LOT I.(com affirm that Section sed 700 ) of Dpjsios on of,th Busi- _ USE OF `^ p 9.(commencing and rotes with Section 7000) of Division 3 of,the B nd BUILDINGS! CHARGES ness and Professions Code, and-my license is 1Po fulPforce'and � - effect - p �7.L,0 l CONNECTION CHARGE FEE t ([ � � CONTRACTOR �A IL License Number I7 ' O Lic.Classes N,• (, 'k17R Q. l0 O I� / ss ADDRESS REIMBURSEMENT FEE Contractor T/k '1 .` Date -v /' r�['-F q -DISTRICT NO GROUP AlMPROCESSED BY 'Z -. CITY �// Q TEL.NCI � �T I��7./TIC (� 7`�/ /�/) ❑ am exempt•u ndeF Sec of the L.A.Co. STATE Ervo: 61 /70 _ CLASS ZL S ��U ^, /C��0S O P.Iumbing Code and/or Sec. of the , No DESCRIPTION OF WORK FEE FINAL s,.-. W HOUSE SEWER CONNECTING TO _ - DATE )) VALIDATION CL - B 8 P.'Code for,the following reason - PUBLIC SEWER' ' — p' 47 H SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL' p "'Z Date' HOUSE SEWER TO By L " - PRIVATE DISPOSAL SYSTEM Signature '. CONNECT'ADDITIONAL BLDG.OR µ - ••� OWNER-BUILDER DECLARATION WORK TO HOUSE SEWEROVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I;am exempt from the.COntrOCtOr s License - .. ExTN.,CESSPOOL.DRYWELL,MANHOLE i a/ rl fessio r the following reason (Secron 7031.5, Buisness and Pro-,`.. SLYER,.ORREPAIRDISPOSAL HOUSE FESSIar15 Eade): SEWER-0RDSPOSAL SVSTEM - - []_I,as owner of.the property,'or'my employees with'.wages as. •their sole compensation, will do the work and.the Structu,e - is not intended or offered for sale (Section..7044; Business and Professions Code). - - 'OWNEI Peijrnf _. s 10 ,570 ❑ 1,.as owner of:thepioperty;am exclusively contracting with. _AUTHORIZATION TOTAL FEE licensed contractors to ConStruct the project (Section . 'I HAVE Z04qAT�TH15 DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOR TO BU5lness and Professions Code). CONNECT THE ABOVEDESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY I hereby affirm that there' is a-construction wending agency SIGNED THIS DAY OF KG� 19� for the performance of the work for which -this permit,. is OWNER OR issued (Sec 3097/,'Civ. C.). ( owNERsnGENTT Lender's Name G I ebKd,L nA �LJp I TL �./� ADDRESS ` �u r/ X, � r f 4V0 11 Lender's Address <A-O( 4, e 6n JAI w/N C.7J - I certify that I have.read•this.appl icotion 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_ - r upon the above-mentioned perry for' inspection Purposes e Signature of Permittee 7 Date — SEE REVERSE FOR EXPLANATORY,LANGUAGE - WORKERS' COMPENSATION DECLARATION I 'hereby affirm that I Have a Certificate'of consent to self t insure•or a certificate of Workers'Compensation tasurance, or 7tA"20. , - •acertified copy thereof.(Sec.,3800, Lab C.) �y, �(`��// /•�� CEsoelkiv 8/51 APPLICATION. FOR PERMIT Policy.NO, Jr 5 Company. ZZ' ('00/6CNV0i� Os. l.J.S"V.fl//TlCC`cAr� ❑-Certified copy IS hereby furnished. - • - -_ .- SEWER -.'SEWAGE DISPOSAL ;"Ceriified'copy is filed with the county building inspection 3 COUNTY OF LOS ANGELES BUILDING AND SAFETY ' ` department. r Q Date aApplicant LQJLL( fAw, P-DOEF FOR.APPLICANT TO FILL'IN, CONNECTION DATA CERTIFICATE OF'EXEMPTION.FROM WORKERS' BUILDING _;�j-p�•7 ,�20� �� 5rnilON .t,15/ 7 H' COMPENSATION INSURANCE;- - ADDRESS 7T'�+T� (This section need not be completed if the workiinvolved by the • • ' ' - - UPPER. LOCALITY [.� MANHOLEREFERENCE- permit is for one hundred dollais ($100)or less') .LOWER NEAREST /"�` TYPE OF CONNECTION LENGTH FROM I certify That d, I s performance of the work for which this CROSS ST. ' c , ». ;J' "CURB 'P.L..- M.L.TO PA is'issued,'I shall not employ any person in any.manner : - so as to become subject to the Workers Compensation Laws. - 'i Pc.Na. . OWNERS A .S" �� CO.IMP.NO. JOB'NO. '5-3'-7,-- "Dote Applicants MA ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: f, after making this Certificate o4 _ AFFlDAVIT WAIVER EASEMENT RECORD.INSTR.NO: DATE �ITYLL/'/K�/rQ' TEL.NO: Ezemptlon,"-you should become subject to-the Workers'' LEGAL - Compensation provisions of the lobar code, you must.forthwith DESCRIPnoN - LOT NO.- - HWY.OR.ST WIDENING comply with-such provisions or this permit shall be deemed .�� O 'revoked: BLOCK TRACT A E ROA MENi - - LICENSED CONTRACTORS DECLARATION I No.OFBmGS MI N 1-hereby affirm that I am licensed under'provisions'of Chapter SIZE OF LOT - Now ON LOT 7 + USE OF p 9-(commencing with Section 7000) of'Division,3'Of the-Bus!..- BUILDINGS (/ /'T 40/ t/,/r% .�.QQ CHARGES. ' ness and Professions Code, and my license'Is in full force and-' � "� effect) CONTRACTOR A ,'O-•yk-R' (/�T/f7� e CONNECTION CHARGE.FEE ' License Number �1/�Q Lic Class '6��/��L.. - -' ` �� - O q / -f G ADDRESS ✓ - S'c�N/// REIMBURSEMENT FEE Comroctor0'-PT 67A-S2 Date 'ZI71C CITY TEL,NO: J�g 7�/ -•�y, •DISTRICT NO. GROUP MAP PROCESSED BY V BK PG Z STATE' /'/ y-7 - LIC. �� ❑.lam exempt under$ec. oflhe L.A_Cp.. ,CENSE No. 7(?1./ !Q C1A55 . � // - �. !' !i� /2 .� O Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE _ FINAL _ HOUSE,SEWER CONNECTING TO PATE [y W 'B. P. Code for the following reason PUBLIC SEWER Zj !�'17 ^! / IYALIDATION N. • - , 5EPTIC TANK,SEEPAGE PIT OR _ / PITS AND/CQ DRAINFIEU) FINAL, Date { T G L - - HOUSE SEWER CONNECTING TO p •T $19nOtUre PRIVATE DISPOSAL SYSTEM CONNECT ADDITIONAL BLDG.OR (/ . OWNER-BUILDER DECLARATION WORKSO HOUSE SEWER ' ,- j I LI f:: L 1 hereby affirm that I'am exempt from the Contractor's License 'OVERFLOW SEEPAGE PIT,DRAINAELD EXTN.,CESSPOOL.DRVWELL,MANHOLE - -Low for the following reason (Secion 7031.5,Buisness and Pro- - ALTER,REPAIR OR ABANDON HOUSE T_`(, >I '} ,=q � fessions Code): • SEWER OR DISPOSAL SYSTEM- - : i ❑ I, asowner of the property,or my employees with wages as their sole compensation, will do the work and the structure ' ' _ - - ld)ANG is not intendedOr offered for sale(Section 7044, Business ` , and Professions Code).; - - ;OWNER'S - Permit IS 0 - ❑:I,-as owner of theproperty, am exclusively contracting with AUTHORIZATION. _.. e g TOTAL FEE _�D T.IGh`!.. --,; licensed'contractors to construct the project (Section 7044; I HAVE AT.THIS DATE A CONTRACTWITHTHE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. i,L]L j y fg 7, • = CONSTRUCTION LENDING AGENCY � 7f �+� ' I, hereby affirm that.there''is a construction lending agency SIGNEDTHIS DAV OE 19 •.for the performance of the work for which' this permit,is OWNERSWNER AGNi issued (Sec. 3097/,, Civ. C.). - - ' L//GlICOAQf , A S77f go}7./ ADDRESS �/ S . 'Lender's Name /� w- .. ` Lender's Address .. - 1.Y17YLZ /rl6 ✓E,. . fY/nq I certify.that I 'have read this application and:stote that the - - - - - - '- above information Is Correct.-I agree'to comply with.all County ordinances and State laws regulating Plumbing and Sewers, - and hereby authorize represeniaiives'of;this County to enter upon Ike abOVe,mentio property for inspection purposes., Cil � A x/89 $ignatureof Permittee ;I SEE REVERSE FOR EXPLANATORYLANGUAGE