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Home My Public Portal About4941 DOREEN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm that f have a certificate of consent to self . irisore, or a,certificate of WorkeTs Compensation Insurance, or 76A6,120 o certified"cop y thereof(Sec. n,. Lab C.) sa000zDPW alae A PPLO, ATBOM'.FOR PERMIT, Policy No.`1(Y 0489(�}/V , .CNA. Ins. Co. YU l�, 11 ❑ Certified copy is hereby furnished. .. SEWER - SEWA0E,DISPOSAL,;.1i� ® Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment Date 2 3 92 ApplicantBros. plur FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING / COMPENSATION INSURANCE ADDRESS Doreen STATION -- DEPTH This section need not be completed if the work involved by the EIIL a Cit UPPER `permit is for one hundred dollars ($100)or less.) LOCALITY p y MANHOTYPE OF LOWER NEAREST _ TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which thisnee CROSS ST. y CURB pL M.L.TO P.I. .permit is issued, shall not employ any person in any manner LL P.C.NO. so as to became subject to the Workers'Compensation LOWS. OWNER ,Curls ConstrUCtion CO.IMP.NO. JOB NO. MAIL115 La' Porte Street TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicont ADDRESS . NOTICE. TO APPLICANT: If, after making this Certificate of CITY Arcadia TFL rlo 574-7355 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE Exemption, you should become subject to the Workers' AL EG Compensation provisions of the Labor code, you must forthwith DEsLPilpJ LOT NO. HWY.OR Si.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT NO.OF BLDGS. PERMIT NO. LICENSED CONTRACTORS DECLARATION size or LOT' NOW ON LOT I hereby affirm that I am ec Tion 00 under provisions of Chapter USE OF - 9 (commencing with Section d my of Division 3 of the B nd BUILDINGS CHARGES nessand Professions Code, and my license is in full force and I effect. - CONTRACTOR CONNECTION CHARGE FEE /� License Numberyy�_LIC Class REIMBURSEMENT FEE 8 /Y1 ADDRESS Contractor OWon ESOS Date 2-92 CITY DISTRICT NO. GROUP BK PG MAP - PROCESSED'BT 0- El Mon TFL NO. — ❑ I am exempt under Sea - of the L.A.Ca. LICENSE NO, 231' 741 CLASS C36-20-16 4rW - 3 Plumbng NO. DESCRIPTION OF WORK FEE ng Code and/or Sec. of the J FINAL 1 HOUSE SINVER SEWER CONNECTING TO �J/ !7. DATE VALIDATION z B. 8 P. Code for the following reason / J L - SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Data HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM SigDOture CONNECT ADDITIONAL BLDG.OR D OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER AINFIELD I hereby affirm that I am exempt from the Contractor's License EEXTNFLOW CESSPOOL.DRSEEPAGEIYWELL, MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 1)_ fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,'as owner of the property,or my employees with wages as lid I °s their sole compensation, will do the work and the structure " `,l jl is not intended or offered for sale (Section'7044, Business and Professions Code). OWNER'S Permit E �'/ .J ; ITE :� ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE lO S3. licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO I Y if l AL 66 5,i Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER, f-L. / , �-. CONSTRUCTION LENDING AGENCY 'IIt�� cam]°`'`� I hereby affirm that there is a construction lending agency SIGNEDTHIS DAYOF 19_ for the performance of the work for which this permit is OWNER OR isiued (Sec. 3097, Civ. C.). OWNERS AGENT Lenders Nome ADDRESS n Lender's Address - i;it: _ A111Q�_ I certify that I have read this application and state that.the above information is correct. I agree to comply with oil County - ordinances and State laws regulating Plumbing and'Sewers, and.hereby outhaIlSe representatives of this County to enter _tfy a -mentione pr a ty for inspection purposes. 3 92 5 gnature of Permute 6te — SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION I hereby Affirm that I.have a certificateof, consent to self ' I ansure or a certificate of Workers'Compensation Insurance, or - 7"M2D - + a•certlfred copy thereof(Se;. 3800, La 92-00T2 DPW 3+96 APPLICATION FOR PERMIT r Percy 1Ja c herebyjp&nY SEWER - SEWAGE DISPOSAL ❑ Certified copy is hereby furnished. - _-' ❑ Certified copy is filed with rhe county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment. //{T Date 3—3/'SZ Applicont'J1 M' 0'O 4c�A A A,l T FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BuaDING - - COMPENSATION INSURANCE ADDRESS '9 [p,U STATION - DEPTH - This section need not be completed if the work involved b the UPPER - ( P Y LOCALITY L �` �l MANHOLE LOWER permit is for one hundred dollars ($I00)or less.), LENGTH FROM I certifythat in the performance of the work for which this NEAREST /' 1 - TYPE Of CONNECTION _ P CROSS ST. �' !/JPS Y.. CURB P.L. MA.TO P.L. permit.is issued, I shall not employ any person in,any manner /� ,/ -{- ac.ND. so os'to become subject to the Workers'Compensation Laws. OWNER ` /-7 k/S / C CO.IMP.NO. J09 NO. MAILTRUNK PERMIT NO ROAD PERMIT NO. Date Applicant ADDRESS -s - p F11 NOTICE: APPLICANT: If, after making this Certificate of CITY WAIVER EASEMENT RECORD.INSTR.NO DATA LC— TEL:NO(O�TT/,S .S AFFIDAVIT Exemption,n, you should become subject to the Workers' LEGAL - Compensation provisions of the Labor code, yau,must forthwith DESCRIPTION LOT NO. HWY,OR ST,WIDENING .Comply with such provisions or this permit shall be deemed - - _ revoked. I BLOCK TRACT 'NO.OF BLOCS. STATE ENCROACHMENT PERMIT NO. LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT thereby affirm that lam,licensedunder provisions of Chapter USE OF. 9 (commencing with Section 7000) Of Division.3 of the BUST- BUILDINGS. - CHLE ARS yyy mess and Professions Code, and my license is in full force and _ effect. CONTRACTOR CONNECTION CHARGE HE License Number 2 � LIC.'Ga33- A ADDRESS REIMBURSEMENT FEE Z Contractor,7M C,wr6++/Y/Date 3 '311 72- tic. DISTRICT NO. GROUP _ MAP PROCESSED BY I CITY TEL.NO. SK PG O ❑ I am exempt under Sec, -of the L.A.Co. STATE No. CLASS Q Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL D-4 _3 -Z -5 HOUSE SEWER CONNECTING TO DATE VALIDATION (n B. 8 P. Code for the following reason Pu SEWER SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL Date HOUSE SEWER CONNECTING TO BY P 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 EXTM,CESSPOOL,DRYWRL.MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER REPAIR OR ABANDON HOUSE TIT{ ==Z 111 fessions Code): SEWER.G (SPOSAL SYSTEM ❑ I,as owner of the property,or my employees with.wages as - �G �•' .tl�'O . their sole compensation, will do the work and the structure -is not intended or offered for sale (Section 7044, Business Ieyf_ :1_'R4 ,n 1C) and Professions Code). OWNER'S Permit ' $ - ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE CH X l54'r1_I licensed contractors to construct the project Section 7044, .. -i" P ( I HAVE AT THIS DATE E CONTRACT WITH THE HEREIN NAMED CONTRACTOR i0 '�d'{;`j':'jl�,[ °' _I_,f Business and PlOf¢ssiOn3 Code). � .CONNECT THE ABOVE DESCRIBED EXISTING DWELLING i0 THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY I herebyaffirm that there is a construction lendin a enc SIGNED THIS DAY OF 79_: - 9 9 -Y lir lrl LI.f1 Or the performance of the work for which this permit i5 OWNER OR - .. IssuedSeC. 3097, Civ. C. OWNERS AGENT ( )' ADDRESS Lenders Name Lender's Address ,. I certify that 1 have read this application and state that the - above information IB Correct. I agree to comply with all County Ordinances and State lows regulating Plumbing and'Sewers, ' and hereby authorize representatives Of this County to 'enter upon t above-ment pro rty for inspection purposes. Signature of Permittee .Dote SEE REVERSE FOR EXPLANATORY LANGUAGE