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Home My Public Portal About6131 CAMELLIA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self 92'0002 DPW 3/87 insure, or a certificatd of Workers'Compensation Insurance, or CE 808 D a certified co y cher of (Sec. 3800, lab C.) CE Boe Policy No.9nthg Company Republic Indemnityof APPLICATION FOR PERMIT ElCertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with a coon y building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY dent/8 9 Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS 6131 Camellia Ave. STATION DEPTH (This section need not be completed if the work involved by the UPPER permit is for one hundred dollars ($100)or less.) NEARELOCALITY Temple City MANHOLE REFERENCE LOWER I certify that In the performance of the work for which this CROSS ST. TYPE OF CONNECTION LENGTH FROM permit is issued, I shall not employ any person in any manner Y. CURB P.I. M.L.TO P.L. so as to become subject To the Workers'Compensation Laws. OWNER Angelo Cubba CO.IMP.NO. JOB NO. MAIL Date Applicant ADDRESS2011 Carolwood Dr . TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, after makin this Certificate o{ Arc . 355-1874 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR,NO. DATE g CITY TEL.NO. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT n I hereby affirm that I 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 Frank Marrone and SOriS Iri effect. CONTRACTOR EONNECTION CHARGE FEE License Number 3 9 7 8 8 4 Lic.Class C/36 4. ADDRESS 98E0 Lower Azusa Rd. REIMBURSEMENT FEE O DISTRICT NO. GROUP MAP PROCESSED BY (,) Contractor Mar r'cirie Date 11/6-/R2 CITY El Monte TEL.NO. 444-2548 BK PG Z El am exempt under Sec. of the L.A.Co. STATE uc L / / O P CENSE NO. CLASS J lQ��—f Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL W HOUSE SEWER CONNECTING TO p0 O DATE VALIDATION a B. & P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR FINAL Z PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY ff PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR , OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD �/ I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE j } fessions Code): SEWER OR DISPOSAL SYSTEM❑ +L-f(jy'I,as owner of the property,or my employees with wages as •4t.T their sole compensation, will do The work and the structure 330727 c4 is not intended or offered for sale (Section 7044, Business e.{'=0 and Professions Code). OWNER'S Permit $ � ITEM ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE,27 d b 27.21_-Q licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ((jj��``��(CC Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWEg 1, ��rT�1%E THE PUBLIC SEWER. .,. �11301 CONSTRUCTION LENDING AGENCY , I hereby affirm that there is a construction lending agency SIGNED THIS Y OF 9_ for the performance of the work for which This permit is OwrOWNERSOAGENT 11130189 issued (Sec. 3097, CIV. C.). ADDRESS 98 LFDwer Azusa Rd. Ei Mont +7164 1 AM11:134 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 ordinances and State laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter up the above- entioned property for inspection purposes. �/Ile I9 Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE - — ' WORKERS'COMPENSATION DECLARATION I hereby Affirm that i have a certificate of consent to self n�ure, or a certificate of Workers'Compensation Insurance, or 76A642D o certified copy thereof(Sec. 3800, Lab C.) 92-0002 DPW 6/88 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 BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN. CONNECTION D ATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS //3/ I/' T �C) (This section need not be completed if the work involved by the A p MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY `hj ,f U '¢' /1780 , NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. A / Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. OWNER Q P.C.NO. /� IN �i�Q�(i(J� CO.IMP.NO. JOB NO. MAIL Date Applicant ADDRESS 6� / /fI r TRUNK PERMIT NO. ROAD PERMIT NO. Q / AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY T TEL.No. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT Jr- NO.OF PERMIT NO. LOT I hereby affirm that I 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. CONTRACTOR CONNECTION CHARGE FEE License Number Lic.Class ADDRESS REIMBURSEMENT FEE Contractor Date DISTRICT NO. GROUP MAP PROLE SED BY CITY TEL.NO. BK PG ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS �+ " 0 Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL CJ HOUSE SEWERCONNECTING TO DATE 0/1� ? VALIDATION B. & P. Code for"the PUBLIC SEWER he following reason SEPTIC TANK,SEEPAGE PIT OR 0 FIELD FINAL PITS AND/OR DRAIN Date BY HOUSE SEWER CONNECTING TO U PRIVATE DISPOSAL SYSTEM _ _ W Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER , z OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE r� jGii; wing reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEMAr�+of the proy,or my employees with wages as QVIP �ACCT* mpensatiwill do the work and the structure r 3730 ed or offered for sale (Section 7044, Business and Professions Code). OWNER'S I Permit $ 1 1 ITE!` ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE TOTAL 21.50 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CIFIRACTORBusiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLI /'�[Y/'��( 2 1X53 CONSTRUCTION LENDING AGENCY4rLw�I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF , CHANGE � I for the performance of the work for which this permit is OWNER OR J+�(. , . issued (Sec. 3097, CIV. C.). OWNERS AGENT Lender's Name ADDRESS 0000-Ml 10!24,8p7 �f��o ,� w Lender's Address MID 1 AM 8:06 1 certify that I have read this application and state that the above information t. I agree to comp y with all County 5the ge-me-d"ntid aregulating PI ing and Sewers, resentatives of his County to enter property for Inspectio Aur oses. mittee Dat SEE REVERSE FOR EXPLANATORY LANGUAGE r WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof(Sec. 3800, Lab C.) 92-0002 DPW 6/88 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 BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS (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 LOWER that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM I certify P CROSS ST. Y. CURB P.L. M.I.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws. P.C.No. P OWNER CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO, Date Applicant ADDRESS NOTICE TO APPLICANT: If, after makin this Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE g CITY TEL.NO. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO, HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT I hereby affirm that I 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. CONTRACTOR CONNECTION CHARGE FEE License Number LIC.Class ADDRESS REIMBURSEMENT FEE DISTRICT NO. GROUPMAP PROCESSED BY �- Contractor Date CITY TEL NO. CL } BK PG 1 y; ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO.TATE CLASS NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the FINAL J HOUSE SEWER CONNECTING TO DATE VALIDATION PUBLIC SEWER B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL >_ PITS AND/OR DRAINFIELD Date BY HOUSE SEWER CONNECTING TO Q PRIVATE DISPOSAL SYSTEM I� Signature CONNECT ADDITIONAL BLDG.OR Q OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ► d I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELD 2EXTN.,CESSPOOL,DRYWELL,MANHOLE W Law far he following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE h— s s Code): SEWER OR DISPOSAL SYSTEM as owner of the property,or my employees with wages as th 'r sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ ❑ 1,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 NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY ► I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which this permit is OWNER OWNERS AGENT issued (Sec. 3097, Civ. C.). 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 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 Date SEE REVERSE FOR EXPLANATORY LANGUAGE