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Home My Public Portal About4846 CAMELLIA AVE_Sewer__ . WORKERS' COMPENSATION DECLARATION - (2 20 0051 DPW 6109 I hereby affirm that I have a certificate, of-•-consent to self • ✓Gsl inse, or a certificate of Workers' Compensation Insurance, or 76A642D ur a certified copy thereof (Sec. 3800, Lab C.) APPLICATION FOR PERMIT Pony Na company S.EdVER SEWAGE DISPOSAL ❑ Certified copy is hereby furnished. - ❑r Certified copy is filed with the county building irispecron COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applimnt FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' " BUILDING // - s COMPENSATION INSURANCE ADDRESS "�'{£ls'+` Noj-A iii L�. ,t (4;� slnnoN DEPTH (This section need not be completed if the work involved by.the MANHOLE REFERENCE uvveR r permit is for one hundred dollars ($100)or less.( LOCALITY _ _ LOWER NEAgEST t TVFTOFCONNECTION LENGTH FROM certify that in the performance of the work for which this CROs sT. ��M,,,/.}( ry { ��.:rA ��L v cuae PL ML rovL permit is issued, I shall not employ any person in any manner LEGAL So as to become subject to the Workers Compensation lows. DESCRIPTION LOT NO. 74:1�q� -7;''(A [:p_"w G} CO IMP No JOB No BLOCK '^� TRACT ( ^'L"f2t TRUNK PERMITINO ROAD PERMIT NO . Dare - Applicant- ASSESSOR ) t+' AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO 'DATE NOTICE TO 'APPLICANT: If, after making this Certificate of MAPBOOrc !O ZJ - PAGE - t0 PARCEL Exemption„ you should become subject to the Workers' � �{ No.of eLOcs. Compensation provisions of the Labor code, you must forthwith SIZE OF LOTNow ON-LOT ( ( Hwv OR ST WIDENING - comply with such provisions or this permit shall be deemed .USE OF . ?> r A ( - revoked. BUILDINGS r.,�.�j{ t�(:.p �L.N. STATE ENCROACHMENT PERMIT NO LICENSED CONTRACTORS DECLARATION OWNER l i F i;j,l} y y�.�+ I hereby affirm that I am licensed under provisions of Chapter V h. L 9 (commencing with Section 7000) of Division 3 of the Busi- MAILCHARGES�'"',F �[,�y `may • - CHARGES ness and Professions Code,'and mV license is in full force and j' +�, !F /� �( effect, CITY �kilI n-4.I.R i { L TEL NO. (.SIL"'� / C/3 �A}'� CONNECTION CHARGE FEE 7 .i License Number LIC.Class - ('Z 1 r REIMBURSEMENT FEE CONTRACTOR IT,r_ E'.Y I-.- ,. �.JI t y.�'� } Contractor Date R 1 J� DISTRICT NO GROUP MAP PROCESSED BY d t ADDRESS LL. I,•r BK PG ❑ lam exempt under Sec. of the LA:.Co, ^' < CITY �,, t L ND ;Z, J Plumbing Code and/or Sec. -sw' ofthe STATE- -^�uc, FINAL VALIDATION w LICENSE NO. CLASS DATE - B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE. Q HOUSE SEWER CONNECTING TO FINAL , a Date PUBLIC SEWER BY _ Q SEPTIC TANK,SEEPAGE PIT OR a Signature; PITS AND OR DRAINFIELD OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO D w PRIVATE DISPOSAL SYSTEM LU I hereby affirm that I am exempt from the Contractor's license CONNEQ ADDmONAi BLDG oR ;j. Law for the following reason (Secton 7031.5,�Buisness and Pro- WORK To HOUSE SEWER 4 OVERFLOW SEEPAGE PIT,GRAINFIELD ss ons Code : r+• J ) ALTER,REPAIR OR ABANDON MANHOLE ti 4L LEER OR DISPOSAL ABANDON MOUSE as owner of the property, or my employees with wages as SEWER DISPOSAL Sv STEM I, s t eir sole compensation, will do the work and the structure yrs is not intended or offered for sale (Section 7044, Business �y• a filt«3%'.' and Professions Code). j ❑ 1, as owner of the property, am exclusively contracting with t34 licensed Contractors to construct the project (Section 7044; - OWNER'S Permit $ +' r /F i',t• f Business and Professions Code). AUTHORIZATION TOTAL FEE CONSTRUCTION LENDING AGENCY �'' '•"" ' HAVE AT THIS DATE A.CRIBED EXISTING WITH THE.HEREIN NAMED CONTRACTOR JO hereby affirm Ih01 there is a Construction lending agency CONNECT THE ABOVE DESCRIBED FxIBTING DwEI11NGI0 ME PUBLIC SEWER , for the performance of the work for which this permit is issued (Sec. 3097, Civ. C)_. SIGNED THIS'DAY OF 19'_ • OWNER OR Leader's Name OWNERS AGENT ON E.e • Lender's Address ADDRESS I certify [hot, I have read this application and slate that the -, above information is correct. I agree to Comply with all County ordlna ces avid State law regulating Plumbing:and Sewers. and eby auh�ar +te gsentatives of-this County la enter _ , u he bbove-'C` d prop ty'fo inspection fp¢,r,)p/oses. b Signature P a,Note 6fe SEE REVERSE FOR EXPLANATORY LANGUAGE ' WORKERS' COMPENSATION DECLARATION aj 20 0051 DPW 6rR9 9 .I hereby ILL, Ihol I nave o certificate of consent to self YYY 'f m��Ce.bifceraficale of Workers'Compensalion Insurance, or 76A6420 Jce.tifiedcopy thereof (Sec. 3800, Lob C.) APPLICATION FOR PERMIT Policy No.` Company ❑ Certified copy is hereby furnishedSEWER - SEWAGE DISPOSAL , ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' A6 BUILDING i n U / STATION DEPTH COMPENSATION INSURANCE ALL (This section need not be completed If the work involved by the MaNHoIE REFERENCE UPPER permit is for one hundred dollars ($100) or less.) LOCALITY FROM LOWER I certifythat in the performance of the work for which this NEAREST ` 1 TYPE OF CONNECTION LENGTH AL p CROSS ST. �� I Y CURB PL ML iOPI permit is issued, 1 shall not employ any person in any manner LEGAL PC NO so as to become subject to the Workers Compensation Lows. DESCRIPTION LOT No CO IMP NO IOB No BLOCK TRACT TRUN<PERMIT NO ROAD PERMIT NO Dote Applicant ^_ NOTICE TO APPLICANT:' If, after making this Cerlificate of AS AFFIDAVIT WAIVER BASEMENT RECORD IN514 NO DATE 9 MAP 80OK PAGE PARCEL Exemption, you should become subject to the Workers' No.of elDcs. Compenso flprovisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF BU revoked. R.DwGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATIONPERMU NO I hereby affirm Thal I am licensed under provisions of Chapter OWNER ` i pez, 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL ADDRESS CHARGES ness and Professions Code, and PI license is in full force and effect. CITTkJ k 'rrVTEL.NO. I R CONNECTION CHARGE FEE License Number Lic Class REIMBURSEMENT FEE r CONTRACTOR Contractor Date DI$i41CS NO GROUP MAP PROCESSED BY ADDRESS E Bx AG ❑ 1 am exempt under Sec. of the L.A.Co. /� 0 p clTr 'L.No. � J� '3 ` a Plumbing Code and/or Sec. of the STATE LI . FINAL TOj LICENSE NO, CLASS DATEVALIDATION Z B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE O HOUSE SEWER CONNECT WG TO FINALIF F Dote PUBLIC SEWER BY (� SEPTIC TANK SEEPAGE PIT OR W Signature PNS AND OR DRAINRELD - h OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING To D ED PRIVATE DISPOSAL SYSTEM, I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR jl Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER -- GVERFICW SEEPAGE PIT,DRAINFIELD - L / ss ons Cade): EMN.CESSPOOL.DRYwfu.MANHOLF mi.!_I a 3 { AITER,REPAIR OR ABANDON HOUSE ISI,as owner of the property, or my employees With wages as cc �r l�t SEWER OR DISPOSAL SYSTEM "!.a)( eIr sole compensation, will do the work and the vrvcture is not intended or offered for sole (Section 7044, Business 1I 1 and Professions Code). 55 _ 35 ❑ 1,as owner of the property, am exclusively contracting with !j}�AL _5 licensed contractors to construct the project (Section 7044, OWNERS Permit $ x 3� I_,t �.`q. m_ __ �H Il .Iyl. ,cr Business and Professions Code). AUTHORIZATION TOTAL FEE t}�� " CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR t0 D CHAP-3E I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED ExISTING DWELLING TO THF PUBLIC SEWER for the performance of the work for which this permit Is issued (Sec, 3097, Civ. C.). SIGNED TFIIS DAYOf I9_ OWNER OR Lender's Name O'WNf RS AGENT 272 by Lender's Address ADDRESS I certify that I have read this application and stale shot The above information is correct. I agree to comply with all County ardina ces and State laws regulating Plu mbinq and Sewers, and by author' a sentotives of this Covmy Io enter u he above- e o prop ry to inspection purposes. Signa Nre Ittee ate SEE REVERSE FOR EXPLANATORY LANGUAGE ,