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HomeMy Public PortalAbout9450 BROADWAY_Sewer__ . WORKERS'COMPENSATION DECLARATION 7z (C' , •^ IT y affirm that hove o certificate of consent to self / IJSI E�, or a certificate of Workers'Compensation Insurance, or 7aAe<sD nified copy thereto �Sec. 3800, Lab C. p CE WE(REV.8/81) APPLICATION, F¢� p ILII L� I� I�I�pp o yNo.S•St93s4ompany S"EQ"�`� '�Lr-.-:d$ ®s AIrP ELL'I� ATIOp�IIpCI, FOR PERMIT ertifiedcopy is hereby furnished, SEWER • SEWAGE DISPOSAL ' ��ertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. p - - Date/G—DZ L> Applicant S4 44S rat. ix.So`_L. FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING - COMPENSATION INSURANCE ADDRESS Q �{S O1�,r,o STATION DEPTH (This section need not be completed if the work involved by the Locnury �- •�. K{- MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)ordess.) LOWER EAREST - certify that in the performance of the work for which This CNROSS T. TYPE OF CONNECTION LENGTH FROM permit Is issued, I shall not employ any person in any manner Y. CURB P.L. M.L.TO PA. 1' so as to become subject to the Workers'Compensation Lows. /' s P.C.NO. G OWNER `SJ �{,.[ - 6 CO.IMP,NO. JOB NO. I TRUNK PERMIT NO. ROAD PERMIT NO 7 Dote � a� Applicant sa'"` c�o:.cz`.$ �"'L AooRE55 �u �P � QV E, ��.3.217tz NOTICE TO APPLICANT' If, otter makingthis Certificate of 'AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO, DATE O CITY p TEL.NO. -/( 2 p ��2- Exemption, you should become subject to the Workers' E�QL �S6 LU LEGAL O 9a Compensation provisions of the labor permit must forthwith DESCRIPTION L O. - HWY.OR ST.WIDENING a comply with such provisions or this permit shall be deemed N revoked. BLOCK TRACT .STATE ENCROACHMENT Z LICENSED CONTRACTORS DECLARATION No. ON LOT OF BLDGS. PERMIT NO, — I hereby affirm that SIZE OF LOT NOW 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 my license is in full force and effect. � p CONTRACTOR S Q t4 ` , $ CONNECTION CHARGE FEE License Number 3.nO (I �-1 LIG / 7 Class `- K ADDRESS '� S �C[ lee-4, REIMBURSEMENT FEE 0. KQ�r Q�l DISTRICT NO. I GROUP MAP PROCESSED BY Contractor Date_� t0— O CITY[,dA;X Id" TEL NO. J 3 CJ`CJ L BK PG ' — Z ❑ I am exempt under Sec. of the L.A.Co. STATE LIC, LICENSE No. CLASS sl0ay ._J( Plumbing Code and/or Sec. of the NO. . DESCRIPTION OF WORK FEE FINAL . HOUSE SEWER CONNECTING i0 DATE PUBLIC SEWER /Q —2 ,I�� VALIDATION B. & P. Code for the following reason ! 3 SEPTIC TANK,SEEPAGE PIT OR Date �V �, �' _ PITS AND/OR DRAINFIELD FINAL HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature' (iT L �C Oi CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER D I hereby affirm that OVERFLOW SEEPAGE PIR,DRAINFIELD am exempt from the Contractor's License EXTN.,CESSPOOL,DRYVI MANHOLE y� Law for the following reason (Secton 7031.5, BUiSness and Pro- ALTER,REPAIR OR ABANDON HOUSE fession5 Cade): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property, or my employees with wages as ,2;R 4 Q,Q 0 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business 0 0 0 4 Q Q Ci U_ - and Professions Code). ,O NER'S Permit g ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION F TOTAL FEE licensed Contractors to Construct the Project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR i0 Business and PrOfe55ions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY - I hereby affirm that there is o Construction 'lending agency SIGNED THIS DAY OF - 19= D for the performance of the work for Which this permit is OWNERS AGENT OWNER OR issued (Sec. 3097, Civ. C.). � - Lender's Name ADDRESS 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 inspection purposes. 'Signature of Permittee DateSEE REVERSE FOR EXPLANATORY LANGUAGE (((((`'''''����� WORKERS' COMPENSATION DECLARATION JI he,reby affirm that have a certificate of consent to self 7or a certificate of Workers'Compensation Insurance, or ZanaaaD a c 5tified copy thereof (Sec 3800, Lab C.)/ / '^] CE aoe(REV.a/ell q��n ��a p 4�®pEl ®�'����oy� Policy Na.'+ ' � 14'rEompany s-+Q +e i-r�s.. ..4 ©s - {'9 IL CA 0 �p�Nr p u, . 0 Certified copy is hereby furnished. `.t. SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection _ COUNTY OF LOS ANGELES- • BUILDING AND SAFETY - :department. ,{ _ f - Date iC -_710-Applicant � �*�o aft L\ S— FOR APPLICANT_TO FILL IN" CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' �( ,P _ (� COMPENSATION INSURANCE ADDRESS I q Sb f� 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 d. �� LOWER I certifythat in the at performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM CROSS ST. Cc` Y. CURB P.L. ML TO PA } permit is issued, I shall not employ any person in any mannerIL so as to become subject to the Workers' Compensation Laws. �p -P,C.NO. O OWNER /\ _ ,R/ d CO.IMP.NO. ' JOB NO. U (� 1. MAIL ( TRUNK PERMIT NO. ROAD PERMIT NO 'L Date/- t--43App I Ica n 5e,�-� dC0 V' 4>` �Ic_��N-L ADDRESS �.p S, A46 NOTICE TO APPLICANT: If, after making this Certificate AFFIDAVIT WAIVER EASEMEN . DATE O ' „K NO 'q T RECORD,INSTR.NOu Exemption, you should become subjectto the Workers'of CITY ers' LEGni w Compensation.provisions of the Labor code 'you must forthwith DESCRIPTION LOT.NO. HWY.OR sT,WIDENING / 1 comply with such provisions or this permit shall be deemed fo•36� y revoked. - BLOCK TRACT _ STATEENCROACHMENT LICENSED CONTRACTORS DECLARATION No.OF BLDcs. PERMIT No. hereby affirm that.l am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE OFi 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and /� effect. (J p /� CONTRACTOR SCph 7jJT t? E..�n CONNECTION CHARGE FEE License Number,�O •� 1� LIC.GIO55 K-� �-)- C%/ 16<- REIMBURSEMENT FEE ' ,%may. ADDRESS Jr�/S J.J '"( ee�� Contractor ,% Sr.. Date �O^� '+ CITY L EL,NO. 3 ..� Cl a(, 5 2 'DISTRICT NO. _ GROUP MAP PR SED BY 5.// BK PG / am exempt under Sec of the L.A.Co. STATE ATE LIC. No. [� ( Cp (::t (.Q LIC. Plumbing Code and/or Sec. of the NO, DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING rODATE ( VALIDATION B. 8 P. Code for the following reason PUBLIC SEWER ZZ 7— +3 r- J SEPTIC TANK,SEEPAGE PIT OR Date CQ— c� PITS AND/OR DRAINFIELD FINAL HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature 17��/ ,-�-� T CONNECT ADDITIONAL BLDG.OR 1 WORK.iO'HOWE SEWER OWNER-BUILDER DECLARATION /C ' hereby affirm that I am exempt from the Contractor's License EEXTNFLOCESSPEOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER, REPAIR OR ABANDON HOUSE' 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 P 1,6 3 7 A is not intended or offered for sale (Section 7044, Business " - and Professions Code). OWNER'S Permit g el ' 0 ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE � licensed contractors to construct the project (Section 7044, 1 HAVE AT-THIS DATE A'CONTRACT WITH THE HEREIN NAMEDCONTRACTOR 10 2,- a 7, 50 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY D a - `2 7,, 5 0 csi I hereby affirm that there is a construction lending agency SIGNED THIS DAYOF 19_ for the performance of the work' for which this peimit is OWNER OR - I 0,26 -83 issued (Sec. 3097, Civ. C.). DINNERS AGENT ADDRESS Lender's Name 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 r 'Ordinances and State laws regulating Plumbing and Sewers, and hereby,authorize representatives of this County to enter - - ' upon the above-mentioned property for in coon purposes: Signmureof Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE