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Home My Public Portal About6026 CAMELLIA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 20-"l DPW&W I I I hereby affirm that I have a certificate of consent to self �� U insure, or o,certlficate of Workers'Compensation Insurance, or a certified copy thereof (Sec. 3800, L APPLICATION FOR PERMIT Policy No. Company ❑ Certified copy Is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy Is filed with the'County building inspection COUNTY OF LOS ANGELES -dUIEDINr,AND SAFETY deport me�t. Dare -7 �-�-J pllcant \opFOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE < t STATION DEPTH (This section need not be completedif the work Involved by the AAkNH E REFER9410E D� permit Is for one hundreGl dollars ($100) or less.) LOCALITY I certify that In the performance of the work for which this NEABT TrPE ION LENGTH FROM CFK088 8T. Y CUIfE PL ML TOP l permit is Issued, 1 shall not employ any person In any manner LF(iAt - r c NO to as to become subject to t}+e Workert' Compensation Laws. DeacFrPrtoH LAT No. cd LMP No f lOe No Date ApplBcant TRACT TRUNPERMIT NO RCIAD PERWT NO NOTICE TO APPLICANT: If, after mokJng this Certificate of MAP Eldon AGE PATacEt AFF DAVIT WAIVER EASEMENT RECORD trtSTR NO DATE Exemption, you should become subject to the Workers NO.OF BL.DGS- Compensation provisions of.the Labor code, you must forthwith ILZE OF LOT Now ON LOT HWY ORST WR]ENING comply With such provisions or this permit shall be deemed USE OF revoked. BUILDINOB STATE 94CROA�WAENT LICENSED CONTRACTORS DECLARATION PERMIT No I hereby affirm that I am Jlcensed under provitions of Chapter OWNER 9 (commencing with Sectlon 7000) of Division 3 of the BwI- OLETEEfB t U� Z aiARGES n&"neand Professions Code, and mV license is In full force and O effect. CAY TEL NO. O 7 U CONINIK7 CHARGE FEE License Number Lic.Clau L COrIYWSCTOR RE NT Connector G-r-O i'2 Date 7-Zf'91� DISTRICT No GROUP MAF PROCESSED BY ADDRESS 6K PG ❑ I am exempt under Sec. of the L.A.Co. ` 1_� , D� _ 3 CITY TEL NO. Plumbing Code and/or Sec, of the ETTATEUCENSE No y_�, � q� B. B.P. Code for the following reason No. ® DOgpnFEE OF WORK -Z VALIDATION 9 HOUSE SEWER CONNECTING TO FINAL . Date PUBLIC SEWER BY SEPTIC TAM.SEEPAGE PR OR Signature PITS AND OR DRAINFIE3D� OWNER-BUILDER DECLARATION NSE SEWER CONNECT WG TO PR ► A I hereby affirm that I am exampt from the Contractor's License CONNECT ADDITIOtW BLDG OR 1l� Law for the following reason (Secton 7031.5, Bulsness and Pro- WORX TO HOUSE SEWER fesslorls Code): � CE EDRXZ= A•Cr'i ❑ I, as owner of the property, at my em to ears with w4 es as ALTER_REPAIR OR ABANDON HOLME L.� their sole compensation, will do the work and the struucture SEWER OR DISPOSAL s i�r7 GG Is not Intended or offered for sale (Section 70", Business 1 1 and Professlons Code). El 1, as owner of the property, am exclusively contracting with OWNEWS Permit f TOTAL 66 - 53 041 licensed contractors to construct the project (Section 7 , j Business and Professions Code). AUTHORIZATION TOTAL FEE I DECK 6.6•2 CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONT W TH THE HEREIN D cON TRACTOR TO , C I hereby affirm that there Is a construction lending agency CONNECT THt ADOVE DESCRIBED EXISTING DWELLING TO THE PUBErC SEWER for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.), SIGNED THIS DAY OF 19_ � ` (i � , OWNER.OR J�,.ri^_1 71 Lender's Name OWNERS AGENT ADDRESS fC*• r 1 AM 3:Z, Lender's Address ��'' I certlfy 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 purpotes. Signature of Piplimittee Date W REVIEW FOR EXrLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certlfltate of consent to self 2MO51 DPW BIBS insure, or a c6rtiflcate of Workers'Compensation Insurance, or 7ME'�D Policy fieri copy thereof (Sec. 3800, L C. APPLICATION, FOR, PERMIT i Policy No. Company SEWER - SEWAGE DISPOSAL t1.YLertifled copy IS �Tereby furnished. ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES 5UILDIgRANRSAfgFY department. Datez-f-f2---Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKE S' BUILDIIIG COMPENSATION INSURMCE STATION DEPTH (This section need not be completed If the work involved by the LOCAREFERENCE UPPER permit Is for one hundred dollars ($100)or less.) HEAFEITY I cert) that In the rformance of the work for which this NFOBT TYPE OF cO CURB ON LENGTH PL certify P4 cFEosa CIT. y permit is issued, f shall not employ any person In any manner CURB P L M i To P L LEGAL P C NO ' sq as to become subject to the Workers' Compensation Laws. DE9CFT1'TIOf1 LOT No. CO ", NO FOB NO Date Appliconl ELOCt( - TRACT TRUNK PERMIT NO Rb,AD PERMrT NO - .. NOTICE TO APPLICANT; If, after makingthis Certificate 'of A AFFIDAV T wArvER EASEWNT RECORD It.*TR NO DATE. MAP BOOK PAGE PAF10EL Exemption, you should become subject to the Workers' No 07FELDo8 Compensation provisions of the Labor code, you must forthwith aqE OF LOT Now ON LOT HWY OR ST WFDPA NG comply with such provisions or this permit shall be deemed LI EOF revoked. Bl1ILDrNGs STATE hc`NT A LICENSED CONTRACTORS DECLARATIOPE RAW NO r I hereby affirm that I am licensed under provisions of Chapter OWNER I 9 (commencing with Seciloh 7000) of Dlvlslon 3 of the BufF- tWl /Z a�ARGEs nets and Profeulons Code, and my license Is In full force and ADORESS ' s effect. qTY TEL No. GONNEL7014 CHARGE FEE License Number Lic. Class c?7 4 i7 � " OWE ` R> r$ �/ � �� t WNTRACTOB M Contractor X 7 Y7 /• Date 7'f� DISTYICT NO GROUP htAP PROCESSED BY ADDRT� a110 BK PG ` 3 y ❑ I am exempt under.Sec., of the L.A Co. � T NO. Olumbing Code and/or Sec. of the STATE F4 NAL LCENSE NO. CLAf3S G DATE VALIDATION Z B. 8 P_ Code for the following reason -POO. DBDCRrTTON OF VMM PEE O HOUSE SEWER 0010,f.ECTING TO FINAL Date PUBI rc SEWER -BY SEOTIC TANK SEEPAGE Rr OR - d Signature PITS ANO OR oRAIWEtD a. OWNER-BUILDER DECLARATION vFIOUSE A SEWER CONNECTrNG TO Z I hereby affirm that I am exempt from the Contractor's License TO FNEADp+T ONAL BLDG OR Lavy for the following reason (Secton 7031,5, Bulsneu and Pro- M�Oroc To HWse SEWER feulons Code): OTRFLOW SEEPAGE PIT,DRAINFELD , EXTt1.CESSPOOL.DRYWELL. El1, as owner of the property, or my emplgyeea with wages aALTER.REPAIR OR AbANDC)N HOUSE A'f;T•Ts SEWER OR DISPOSAL SYSTEM �� their sole compensation, will do the work and the structur6 33D-T [,6,,y, is not Intended or offered for sale (Section 7Q", Business �- and Professions Code). t f IM tt El 1,qs owner of the property, am exclusively contracting with OWNER'S Permit f �rIY } ��ir, licensed contractors to construct the profect (Section 70L", Business and Professions Code). AUTHORIZATION TOTAL FEE rel ,536 CONSTRUCTION LENDING AGENCY I HAVE AT THIS GATE A CONIRACT WITH THE I-CREW NAA&D CWR,LCTOR To, , 2 L1h� I hereby affirm that there If a cohstructfon lending agency CONFECT TFE ADOVE DESCRIBED EXISTING DWELLING TO T1,E PUBLIC SEWER ['f{j � �[ for the performance, of the work for which this permit is issued (Set. 3097,Civ. C.). i 1 SIGNED THIS DAY OF 19_ ' Lender's Name O RSA('� NT 0311—oi 7f25/92? Lender's Address ADDRESs .j 1 rel , 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 Coynty to enter upon the abo v mentioned property for Inspection purposes. Signature of Perml ee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE r