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Home My Public Portal About9439, 9441 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 7eA6a2D - acertifiedcopythereof(Sec. 3800, Lob C.' CE J � 'CE 80 (REV.8ie)7 Policy NoOlj5705 Company 5L • APPLICATION FOR PERMIT , �❑+Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL - YY Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY DaZWTdepo tm n /.�. Applicant OJ(LC 1QN/l � Lbw FOR APPLICANT TO FILL IN CONNECTION DATA ' CERTIFICATE OF EXEMPTION FROM WORKERS' Bwl01NG ADEJ 2 R STATION - O•�. DEPTH COMPENSATION INSURANCE DRESS TJ (This section need not be completed if the work involved by theUPPER NEAREST LOCALITY '—r�1E � TYPE OF CONNECTION LENGTH FROM LOWER - MANHOLE REFERENCE 9�J permit is for one hundred dollars ($100)or less.) [_ I certify that in the performance of the work for which this CROSS ST CLOVEYZ�-Y v. NECURB P.L. LEN TO P.L. permit is issued, I shall not employ any person in any manner so as to become sub'ect to the Workers'Compensation Laws. �p,�tI ��1L s P.C.NO. , I P OWNER /�.y {(Jr/ /L�FLS �/�R CO.IMP.NO. JOB NO. � L3 MAIL TRUNK.PERMIT NO. ROAD PERMIT NO Date Applicant ADDRESS /JD /A /'TA /Nt 7Q NOTICE TO APPLICANT: If, ober making this Certificate Of CITYTEL.NO. X56 5/ AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE Exemption, you should become subject to the Workers' Compensation pro isions of the Labor code, you must forthwith LEGAL P P Y DESCRIPTION LOT NO. HWY.OR Si.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT ri¢j(! TIEN ROA MINT Ef.T4 LICENSED CONTRACTORS DECLARATION NO OF BLDGS. p _/� CI I hereby affirm that I am licensed under provisions of Chapter SIZEOFLOT• NOWONIOT V uSE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUIL01NGS ffµ✓ / y(/ CHARGES ness.ond Professions Code, and my license is in full force and C {, CONNECTION CHARGE FEE r effect. t�'�.( /, L]��L CONTRACTOR 1 License Number •v/'/�1 -`� Lic.Class �A�/Kr(�Ca-Q/I� ADDRESS �'v �, � � REIMBURSEMENT FEE O Contractor C/TA 6w5r. Date -a/7/&!/ l j iY�/�'l� DISTRICT NO. GROUP MAP PROCESSED BY V CITY TEL NO 1 r'(�/ J (y/ K// z BK PG '//"'� ZO ❑ I am exempt under Sec. of the L.A.Co. STATE ENSE NO. ( 7a Ci 55 �Q!•/� 5��Q •` -/ $b /�� Plumbing Code and/or Sec. ofthe NO. DESCRIPTION OF WORK FEE FINAL /,,,A//// U HOUSE SEWER CONNECTING TO D Q DATE �('/ y VALIDATION d B. 8 P. Code for the following reason PUBUC SEWER / Q (, _. H SEPTIC TANK.SEEPAGE PIT OR Z PITS AND/OR DRAINFIELD FINAL �.p/m,.w f d Date HOUSE SEWER CONNECTING i0 BY PRIVATE DISPOSAL SYSTEM - Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER _ hereby affirm that OVERFLOW SEEPAGE PIT,DRAINFIELD am exempt from the Contractor's License EXTN.,CESSPOOL.DRYWEIL MANHOLE Low for the following reason (Secton 7031.5, Buisness and PFO- ALTER,REPAIR OR ABANDON HOUSE m 590fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as - their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business ��•"• J= '- and Profession$Code). OWNER'S Permit S 0 5Dn - ❑ 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 EMSTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY 7 i}i �� IJ" •L I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 14210119iF7 D for the performance of the work for which this permit Is OWNER OR pp OWNERS AGENT l issued (Sec. 3097, Civ. C.). Lender's Name ADDRESS Lender's Address u��V[,; V/�.'ff F"— Ar 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-mention property for inspection purposes. " I8y Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION ' n I hereby affirm that I have a certificate of consent to self '.II insure, or a certificate of Workers'Compensation Insurance, or JeAe<aD !S a certified copy-tRh•e�re.of (Sec. 3800, Lab C.1 OF 80(REV.Biel) APPLICATION, ��n �ffa p��®�i ®� ��8� Policy No.�Compony S% Cd K1AW,"nOz✓ Os A IL 'i A ❑,Certified copy is hereby furnished. i sve. ela. SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection 113 COUNTY OF LOS ANGELES BUILDING AND SAFETY depart e Date Applicant �ILLfQcu � -. -.. FOR APPLICANT TO FILL IN A43/,DO CONNECTIONDATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING �y COMPENSATION INSURANCE ADDRESS �j-'/%/ /J Y. STATION DEPTH (This section need not be completed if the work involved by theLOCALITYTFn,P�c MANHOLE REFERENCE p.r•95,� - UPPER permit is for one hundred dollars ($100)or less.) LOWER NEAREST TYPE OF CONNECTION LENGTH FROM Z- certify that in the performance of the work for which this - permit is issued, I shall not employ any person in any manner CROSS ST. CLO vew LOWNER /I Y S LT CO.IMP.NO..: CURB P.L. MATO P.L. __-J, so as to become subject to the Workers'Compensation Laws. P.Bc.,NO.NO: - 3%'/J JO3 MAILC F .c O TRUNK PERMIT NO. ROAD PERMIT NO, Date Applicant ADDRESS rf, NOTICE TO APPLICANT: If, after makingthis Certificate Of Q/G (1// -�� AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO. DATE CITY TEL.NO. G O /7 Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. 'H WY.OR Si.WIDENING ' comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT 0 ATf NC AC VENT LICENSED CONTRACTORS DECLARATION NO.OF LDGS. IT o.SIZE OF LOT t� NOW ON LOT- •// G /1 L� / I hereby affirm that I am licensed under provisions of Chapter USE OF /�/ L6K.1 9 (commencing.with Section 7000) of Division 3 of the Busi- BUILDINGS Of //�(/T CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTORA,.�' /•t E C_??QA (LI, CONNECTION CHARGE FEE >, License Number yG/97o Lia Class "- ` ADDRESS �,SQ / �E OCL v /b r q (^ y REIMBURSEMENT FEE Contractor f�Yr/ CdA'57. Date CITY (,/ " q TEL.NO. G�4 �/�' �( DISTRICT NO. GROUP MAP PROCESSED BY ❑ am exempt under Sec. of the L.A.Co. LICENSE NO. / l / 7o CLASS C �/ Soo �� K �� Q � E.OF.... - Plumbing Code and/or Sec - of the NO. ,-DESCRIPTION OF WORK FEE VFINALG Ey HOUSE SEWER CONNECTING TO 17 Da DATE /p �/ ?8/ VALIDATION d B. 8 P. Code for the following reason PUBLIC SEWER : Z SEPTIC TANK,SEEPAGE PIT OR PLL$AND/OR GRAINFIELD FINAL Date HOUSE SEWER CONNECTING i0 6Y - PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER _h D 1 jti f� I hereby affirm that I am exempt from the Contractor'sOVERFLOW SEEPAGE PIT,DRAINFIELD License EXTN..CESSPOOL,DRYWEtt,MANHOLE Law for the following reason (Secton 7031.5, Buisne5s and Pro- ALTER,REPAIR OR ABANDON HOUSE _ 50 El fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as � �'• �?•' -( their sole compensation, will do the work and the structure e)1)� is not intended or offered for sale (Section 7044, Business - and Professions Code), OWNER'S Permit $ -d sr7 ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 2-7 project (Section 7044 5 - - - :licensed contractors to construct the ecton , :1. h'-r; 7j.j P I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DEXRIgED EXISTING DWELLING TO THE PUBLIC SEWER. ', ] 4jtj j �e =- CONSTRUCTION LENDING AGENCY76'/`/' ,{' D 1 I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19 1 for the performance of the work for which this permit is OWNER issued (Sec. 3097, iv. C.)y,,�- I A /�,� �✓ OWNERS AGENT,.( L-Ir L I/ VIW I!TFk//� ADDRESS Lender's Name ' Lender's Address �� I certify that I have read this application and stat 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-menti d property for inspection purposes. ejl w. 3171 di Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE