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Home My Public Portal About9437, 9441 , 9445 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 7eAb 21) - a certified copy thereof (Sec. 3800, Lab C.) CE BOB(REV 8i81) APPLICATIONPolicy No�Company ll• J FOR PE RMT U Certified copy is hereby furnished./v SLI2 " ~� SEWER • SEWAGE DISPOSAL ❑ Cerlified copy is filed with the county building inspection3 COUNTY OF LOS ANGELES BUILDING AND SAFETY .department. Ic.�(AAk � Date 3h/��Applicant WW P FOR APPLICANT TO FILL IN CONNECTION DATA' CERTIFICATE OF EXEMPTION FROM WORKERS' BuuDING - f COMPENSATION INSURANCE ADDRESS STATION4 /5, "7• EPIH' (This section need not be completed if the work involved by the LOCALITY G MANHOLE REFERENCEO V UPPER permit is for one hundred dollars ($100)or less.) - LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that d the performance of the work for which this CROSS SL C >.r v.` CURB P.L. M.L.TOPL.__ permit is issued, I shall not employ any person in any manner ^. nn P.C.NO. �� so as to become subject to the Workers' Compensation Laws. OWNER /•[)( A (Mpg L CO.IMP.NO. JOB NO. Date Applicant ADDRESS Aga /� _ p V� �E 7� TRUNK PERMIT NO. t ROAD PERMIT NO, NOTICE TO APPLICANT: If, after makingthis Certificate of a/, �•{'/�' V`17_ tl AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY u.� TEL NO.Vr 7 T Exemption, you should become subject to the Workers' Compensation provisions of the Labor code, you must forthwith LEGAL DESCRIPTION LOT NO. HWY.OR ST.WIDENING / comply with such provisions or this permit shall be deemed / revoked. BLOCK TRACT 6 T EE R CH Ni nq.OF BLDG // P i LICENSED CONTRACTORSDECLARATION provisions SIZE OF Lot Now ory LO h (�l.l.l hereby affirm that am licensed under provisions of Chapter USE OF E / 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS UK k' UK- V'/V CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR (� Q ( CONNECTION CHARGE FEE 6 License Number 4161��}V• Lic.Class/`//EJ✓E/AL ADDRESS IiSb N' e r „- - Arfe�/ 4' Q REIMBURSEMENT FEE V CO nhactOrO//7 `G^^-•V. D012 �/ �/� CITY r TELNO(O/I 4kl`7/--^�ZC�(,, DISTRICT NO. GROUP MAP PROCESSED BY BK PG I Z ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. W-7(3 CLASS ITGNK�L S Q , K iJi S S/D �ep5 O NO. DESCRIPTION OF WORK FEE ccs+ u Plumbing Code and/or Sec. of the FINAL q - - FgUSE SEWER CONNECTING i0 7 D v PATE XLT 1Z F :VALIDATION d B. 8 P. Code for the following reason PUBLIC SEWER VV 0 / Z SEPTIC NANO,SEEPAGE PITUD OR i PITS AND/OR CONNECTING FINAL f}L �; DOIe HOUSE SEWER CONNECTING i0 BY PRIVATE DISPOSAL SYSTE Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK i0 HOUSE SEWER' hereby affirm that I am OVERFLOW SEEPAGE PIT,DRAINFTELD exempt from the Contractor's License EXTN...CESSPOOL.DRYWEU.MANHOLE "'J' @ �� Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM .�-7 jU El 1,as owner Of the property,or my employees with wages as ,I II7 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 E -)O .f� _ Ll 1, as owner of the property,am exclusively Contracting with AUTHORIZATION TOTAL FEE E,ji '.I)^1jl'I!f `1�� 7 j L2'D to contractors construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO j. .0 1 -IF lte X,1 BUSIneSS and PTOfe5510n5 Code). CONNECT THE ABOVE DES41BED EXISTING DWELLING TO THE PUBLIC SEWER. --• - CONSTRUCTION LENDING AGENCY 'dU �[ D I hereby affirm that there is a construction lending agency SIGNEDTHIS DAYOF V�•'1/ 19.� for the performance of the work for which this permit is OWNER OWNERS OAGENT R / A, issued (Sec. 3097, Civ. C.). ADDRESS (dam r'r• -1 � 7V Lender's Nome L/ p/Q J�%� GY7J,T✓ �`� c Lender's Address /K-U-s.IA LE Cp L/(/..A} /l,C.A f CA 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, Lind hereby authorize representatives of this County to enter - - upon the above-mention a property for inspection purposes. Signature of Permittee Dole REVERSE FOR EXPLANATORY LANGUAGE I •. '' 'SYORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insuiq,.or a Certificate of Workers'Compensation Insurance, or >aAwsD -•a certified copy thereof (Sec. 3800, Lob C.) CE BOB(REV.8/81) APPLICATIONPolicy Np.h7,5 ompany ST CffAhl ' FOR PERM IT ❑.Certified copy is hereby furnished. IA/SV2• AW4O SEWER SEWAGE DISPOSAL ' ( ertified,copy is filed with the county building inspection COUNTY OF LOS ANGELES 'BUILDING AND SAFETY d-e 1&� Applicont� �( IRNpaDate � FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGq p � ' COMPENSATION INSURANCE ADDRESS �3 lW x STATION �5, EPTH (This section need not be completed if the work involved by the LOCALITY , MANHOLE REFERENCE UPPER LOC permit is for one hundred dollars ($100)or less.) 3 LOWER NEAREST �nsvf TYPE OF CONNECTION LENGTH.FROM certify that in the performance of the work for which this CROSS ST, L.a/eyu- Y- CURB P.L. WL.TO P.L. "t permit is issued. I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. OWNER 1 n X - ( `J ?-71J0. CO.IMP.NO. MAIL ] y. Dale Applicant ADDRESS G L� Ill"` TRUNK PERMIT NO. ' ROAD PERMIT NO, NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. - 1 S [,l 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 ST.WIDENING comply with such provisions or this permit shall be deemed •�''JE�q _ revoked. - BLOCK. TRACT f O V� E R CH T DG LICENSED CONTRACTORS DECLARATION [ NO.OF BLS. / P N . SIZE OF LOT Rif NOW ON LOT �N C0�5r I hereby affirm that I am licensed under provisions of Chapter USE OF - 4/7 Sr 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDING A//'r CHARGES ness and Professions Code, and my license is in full force and effect. �"I �,y� CONTRACTOR I� CONNECTION CHARGE FEE `� License Number 71L Lic.Class Goxfl ll L - Y d /� ''F yvGF ADDRESS (, QQ VQ.. REIMBURSEMENT FEE Q Contractor D4'A f-ONt.' Date a-w ! CITY 4 TEL.N // O l J q 7-Sq(44 DISTRICT NO. GROUP MAP PROCESSED BY V BK PG Z PSec.—of- STATE OIC. e-' 5 4 �� l A < O ❑ I am exempt under the L.A.Co. LICENSE No.q6 (9 V LIC, 6Q,N(.l. ((//oo '(CLW 0 NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec of the NO, _VALIDATION B. HOUSE SEWER CONNECTING i0 DATE / �/•� d B. 8 P. Code for the following reason PUBLIC SEWER � dQ (� SEPTIC TANK,SEEPAGE PIT OR FINAL Y:4�J-t ` PITS AND/OR DRAINFIELD �i�yy]�/].� Date HOUSE SEWER CONNECTING TO BY 'L_ yv-0 PRIVATE DISPOSAL SYSTEM -i� Signature CONNECT ADDITIONAL BLOC OR W OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER D i I TEMS OVERFLOW SEEPAGE PIT,DRAINFIEL) I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL.DRYWELL.MANHOLE j}T.`)i ' 27 . 50 Law for the fallowing reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM �•(:� 7,:j6 i 4>?_... ❑ I,heir owner of the property, or my employees with wages re -,-INOG— .j{i] their sole compensation, will do the work and the structure _ i,...t 71: is not intended or offered for sale (Section 7044, Business permit g I and Professions Code). OWNERS ❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE (1T`f'_rI_j_Ij 'I~ licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONI ACTOR TO Business and Professions Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING r0 THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY -7 1)4 ` N I hereby affirm that there is a construction lending agency SIGNED THIS DAV OF 19 D for the performance of the work for which this Permit is OWNER OR 1 p p OWNERS AGENT AIL(/��i� J'(N9 - issued (Sec 3097(/,OCLiv. ADDRESS I J /.TWIN IH'L.C- 'T / - Lender's AVE /' 1 Lender's Address C�110,IL ..O /'IC • L OV),J-4 AI CA I - ''Lcertify that I have read this application and state that the above information incorrect. I agree to comply with all County tordinances and State laws regulating Plumbing and Sewers, - and hereby authorize representatives of this County to enter upon the gbove-mentioned propert for inspection purposes. . Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE