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Home My Public Portal About5830 CLOVERLY AVE_Sewer__ WORKERS'COMPENSATION DECLARATION 76 808 D-80) /�� APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING s- / J / STATION DEPTH ADDR ESS ��l��y�. .,G_ Z,/' Certified copy is filed with the c?unty building i gpection ^ uPPE department. �s p.� LOCALITY '� MANHOLE REFERENCE 5 LOWER Date•n Applicants-� NEAREST �� TYPE OF CONNECTION LENGTH FROM/,5, CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss sr. �[>irs >, s) Y. CURB P.L. M.L. TO P.L. FROM/, COMPENSATION INSURANCE P.c. No. OWNER �' d -� .rfi�.t��C` �;C7 �, CO. IMP. NO. JOB NO. MAIL / d (This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO{/ O by the permit is for one hundred dollars (7Q100) or less.) �Jf`r�= AFFIDAVIT I WAIVER EASEMENT RECORD. INSTR.NO. DATE e.) CITY,, —.sJ•-'�•TyYJ I certify that in the performance of the work for which this LEGAL tr permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING 0 so as to become subject to the Workrs' Compen$ation Laws. ) BLOCK �- TRACT STATE ENC RO HMENT (t LUDate 7 � Applicant�g_ W-r- NO. OF BLDGS. PERMIT NO. N NOTICE T6 APPLICANT: If, after making this Certificate of slzE of LOT Now ON LOT Exemption, you should become subject to the Workers' USE OF CHARGES — Compensation provisions of the Labor Code, you must forth- BUILDING with comply with such provisions or this permit Shall be CONTRACTOR CONNECTION CHARGE FEE Z deemed revoked. ' REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS y G � % �y�� iP. DISTRICT NO. GROUP MAP PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter CITY J`�z ,} TEL. No.� <,/� j Wiz', BK PG ` 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and STATE ^ / LICd LICENSE NO. CLASS �'S�.7 �,F_$'� LA 55 ��r, L��'7e ` � /v`J effect. NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO FINAL -� VALIDATION License Number Lic.Class PUBLIC SEWER DATE SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD Contractor Date FINAL i HOUSE SEWER CONNECTING TO BY ❑ PRIVATE DISPOSAL SYSTEM I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD lnesS and Professions Code). EXTN.,CESSPOOL,DRYWELL,MANHOLE ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic,or Reg.No. Date HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNERS Permit s z 4 2 5 4 A License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE 0 0 0 0 1 0 ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREI NAMED CON- OYRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I, as owner of the property, will do the work and the TO THE PUBLIC SEWER. Z 0 0' 1 B O O structure is not intended or offered for sale (Section SIGNED THIS qAY OF —'— 3— 19,41 7044, Business and Professions Code). OWNER 0 //��/� 0 0 01 a00= OWNERSf CONSTRUCTION LENDING AGENCY ADDRESS 0.227-81 I hereby affirm that there is a construction lending agency (% ' for the performance of the work for which this permit is6`� �� (/ issued(Sec. 3097,Civ.C.). (/CJl Lender's Name y 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 ordinance's and State laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE C1 Signature of Permittee ,Date / WORKERS'COMPENSATION DECLARATION 76A642D APPLICATION FOR PERMIT {� CE 808 (2-80) r �o L J I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL insure, or a certificate of Workers'Compensation Insurance,o-r a certified copy thereof(Sec. 3800, La .) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy Nq��IK" 4' Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING STATION DEPTH Certified copy is filed with the county buil din iBBnspection ADDRESS UPPER department. //L LOCALITY �- I < MANHOLE REFERENCE �^1 / j LOWER Date -�- 7A Applicant. /�'fS�lf/./ � NEAREST �' TYPE OF CONNECTION LENGTH FROM /L CROSS ST. S Y. CURB P.L. M.L. TO P.L. L �J C RTI ICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE I c. No. OWNER J,� �' ,/�� c� p CO. IMP. NO. JOB NO. MAIL (This section need not be completed if the Qwork involved ADDRESS 4/a1 r l of any / ' TRUNK PERMIT NO. ROAD PERMIT NO. (— � by the permit is for one hundred dollars ($100) or less.) �.* yyEC��Y AFFIDAVITWAIVER EASEMENT RECORD. INSTR. NO. DATE 0 C ITy 9r♦ TEL. NO. I certify that in the performance of the work for which this LEGAL permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING so as to become subject to the Work rs' Compens on Laws. 0 Comp BLOCK �� TRACT STATE ENCROACHMENT 0 Date S; o Applicant _ �/�' PERMIT NO. NO. OF BLDGS. W NOTICE T APPLICANT: If, after making this Certificate of slzE of LOT NOW ON LOT Exemption, USE OF p you should become subject to the Workers' BUILDINGS CHARGES Compensation provisions of the Labor Code, you must forth- _ with comply with such provisions or this permit shall be CONTRACTOR CONNECTION CHARGE FEE deemed revoked. �' e ` q /�. REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS x-' '�� _ �� ? I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP MAP PROCESSED BY BK PG 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and STATE LIC. (►6 LICENSE NO.��y� ,� '�� CLASS �— � '� ` 6( `Q' effect. NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO FINAL VALIDATION License Number Lic.Class PUBLIC SEWER DATE SEPTIC TANK,SEEPAGE PIT OR Contractor Date PITS AND/OR DRAINFIELD FINAL HOUSE SEWER CONNECTING TO BY ❑ PRIVATE DISPOSAL SYSTEM I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD iness and Professions Code). EXTN.,CESSPOOL.DRYWELL,MANHOLE ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNER'S Permit s License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE z 2 Jr A ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- {/ ❑ YRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING t'} O O O.O 1 0 I, as owner of the property, will do the work and the TO THE PUBLIC SEWER. structure is not intended or offered for sale Section y� ( SIGNED THIS '7 U Y OF _g-,,,`==, - 19`� 2 O - 40. 00 7044, Business and Professions Code). OWNER OR /L L�✓j� /�y`�f OWNERS AGENT CONSTRUCTION LENDING AGENCY ADDRESS D O 040002: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is /�� /f 0227-81 issued (Sec. 3097,Civ.C.). �4�l 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. SEE REVERSE FOR EXPLANATORY LANGUAGE ' �'v Signature of Permittee Date