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HomeMy Public PortalAbout6029 CAMELLIA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certlficate of consent to self Insure, or a certificate of Workers'Compensation Irnuranc*, or a certified copy thereof(Sec. N001 C.) n-°°O12°MSOW APPLICATION FOR PERMIT Policy No. Company ��� Kwiffied ertified ropy is hereby fumished. SEWER - SEWAGE,DIVOtAL �l copy u filed with the u ty bu lnq I on ,COUNTY OF LOS ANGELES dUIN�AND�SAFETY II d en LJ Date�Appllcant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF FROM WORKERS' eUSDtNu COMPEIJSAT} NC ON INSURANCE ADOFtf33 STATION DO" (This section need not be completed if the work Involved by the UPPER permit Is for one hundred dollars (;100)or less.) LOCNM NEAREST TYOE OF �FROM I certify that In the performance of the work for which this Sr. Y. � P.L. - �WLTTO P permit Is Issued, I shall not employ any person In any manner P c No to as to become subject to the Workeri.Compensation Laws. OWNER aAr-4 CO u�p Poe No. 'ms's' TRUNK PBOW Na ROAD PB MKT NO. Date Applicant ADDRM1 ` NOTICE TO APPLICANT: If, after making this Certificate ofO1Y TEL..NO. ARMAYTT wArM eAS&AENT RECORD.parts Na DATE Exemption, you should become subject to the Wgrkws' LEGAL Compensation provisions of the Labor code, you must forthwith DESQPTION LOT NO. Frwr.OR ST.wtOgaNG campiy with such provisions or this permit shall be deemed J revoked. - BLOCK / 'FATE r3JCROMfttAVClT NO.OF ELDGS. PESM7 NO. LICENSED CONTRACTORS DECLARATION - ��Lm Now oN LOT I hereby affirm that I am licensed under provisions of Chapter USE or 9 (commencing With Section 7000) 9f Division 3 of the Bust- euaprpt{ any nese and Professions Code, and my license Is In full force and effect. CONTRA<.TOR47 10 cCNNE TN aIARAE FEE License Number c Class 71 A-009 Contractor, & t7afe � DrsratCT No. GROUP MAP PROCEfQM[rr QTY TH.NO. BK PO ❑ I am exempt under Sec of the LA.Co. STATE NO. Q tis , 3 IL O FEE Plumbing Code and/or Sec of the �' NOQSEEI Cor�tt�i TO DATE VA1116ATION 1!tB. d P. Code for the following recwn P L- Sffi�AW PF(OR O HTi AAD DRAJNFIFLD FlNAL F- Date FIOUSE stwet CONNECTING TO By 747�;lw a Signature ADDMONAL ELDO.OR , C/) OWNER-BUILDER DECLARATION VK=TO HOUSE SEV16t Z I hereby affirm that I am exempt from the Contractors License 9 ..FKLE Law for the following reason (Secton 7031.5, Bulsness and Pro- A1Tet REPAIR ORAAANDON SYSTEM 10 fesslons Code): a� �T.�r ❑ I,ca owner of the property,or my employees with wages as their sole compensation, will do the work and the structure M7 34.50 Is not Intended or offered for sale (Section 70 J, Builness and Professions Code). OWNIR'i Permif s 1 ITpMS ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE TOTAL 34.50 licensed contractors to construct the project (Section 7044, I HAVE AT TFrtS DATE A CONTRACT WITH THE HEREFN N�CONTRAL7M TO Business and Professions Code). Ct*�THE Above D50aND POSTING DK731Pl6 TO THE%MLIC WDA ({,E('{( 34.50 CONSTRUCTION LENDING AGENCY `w• 1 hereby affirm that th'o a Is a construction lending agency a�cr®oa DAY 19 lop - �00 for the performance of the work for which this permit is OWNERS R Issued (Sec 3097, Civ. C� ADotrEss �-�1 4/12/90 Lenders Name " IA1 AI110� certify 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 hero authorize representatl f this County to enter upon t vein Honed pr Inspection purposes Slq re o ttDate SO VZVEW Mt LPLANATORY LAM UA0i DEPAIt'fMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1 DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEER BUILDING ADDRESS !! FOPPLICANT TO F1L IN LOCALITY BUILDING NEAREST ADDRESS zk' G CROSS ST. LOCALITY DISTRICT N0. SERIAL N0. PERMIT NO. NEAREST >1 �` S CROSS ST. t - =+ RECEIVED BY Ready for Inspection DATE ISSUED OWNER MAIL ���7� USE ZONE OCCUPANCY **P_ ADDRESS j� BK PG CITY �� TELAO. of J�CrJ""'� �5 P=i CONTRACTOR 4e /30 CO.IMP.N0. F? ADDRESS ©• JOB N0. CITY /yam /tom es TELAO.[, / f TRUNK PERMIT NO. ! STATE REGISTRATION N0. Q� COUNTY ROAD PERMIT N0. LEGAL f STATE ENCROACHMENT DESCRIPTION LOT N0. PERMIT NO. w ^^ BLOCK TRACT67 INDUSTRIAL r WASTE APPROVAL SIZE OF LOT ✓ ,` %'8F BLD68. NOW ON LOT CHARGES USE OF BUILDINGS CONNECTION CHARGE FEE NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO r REIMBURSEMENT FEE PUBLIC SEWER @ $ 3.50 J RECEIPT NO. /DATE I BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR ^ EXCEPTION RECORDED WORK TO HOUSE SEWER 1.00 L/ ALTER OR REPAIR EXISTING NO. I DATE I BY SEWER OR DISPOSAL SYSTEM 1.00 DISCONNECT AND ABANDON SEWER AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD 2.00 STATION DEPTH ;l J CESSPOOL—DRYWELL SPECIAL CONDITIONS ONLY 2.00 J MANHOLE REFERENCE r TIPPER S LOWER, v -- TYPE OF-ZbAECTION LENGTH FROM OWNERS PERMIT $ 1 00 cuR6 _ M.L.TO P.L. AUTHORIZATION TOTAL FEE I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE DWELLING TO THE PUBLIC SEWER SIGNED THIS.....:��z/_a__._-___DAY OF.... NEW HOUSE SEWER i r OWNER ORCONNECT ADDITIONAL -/ p OWNERS AGENT-/ �.L GC.c"�' i� BUILDING OR WORK _______. / !! SEPTIC TANK,SEEP.PIT(S) ADDRESS--------------�..f��._a____._.__.._.:._.._���....__.__._...__._.c... AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELL E] CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND DISCONNECT PLUG AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ER OF THE ABOVE D SCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKSO f SIGNATURE , > SEEP.PIT(S)[] CESSPOOLS l`�t 4w'� OF PE . ITTEE_ .._. .... �=e=:_ii'c:i____1Z1:L_ 1� T6A642D 663 1/53