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HomeMy Public PortalAbout4503 ELLIS LN_Sewer__ 76A642 WORKERS'COMPENSATION DECLARATION CE 808 (D2-80) APPLICATION FDISPOSAL RPERMIT I hereby affirm that I have a certificate of consent topself SEWER-SEWAGE ®0 S POSA L insure, or a certificate of Workers'Compensation Insurance,or { a certified copy thereof(Sec. 3800.Lab.C.) d;4 COUNTY OF LOS ANGELES BUI LDING AND SAFETY +( Policy No. Company'A$z� �p �' �G / G /S!•-•57-43' _ FOR APPLICANT TO FILL IN 1:2-3- CONNECTION DATA Certified copy is hereby furnished. _ BUILDING T ��/ � ^ -e-- ST'T ION DEPTH Certified copy is filed with the county buildin inspection ADDRESS �V �� �'--t.5 /-f-�^ / / � � ' department. / n MANHOLE REFERENCE ��t O ?(( .Y LOCALITY f� /� / 4, VM/ LOWER Date Il-l3^ 'I Applicant NEAREST TYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. Gec stL�� 2_a-S� - Y. CURB P.L. M.L. TO P.L. P.c. NO. OWNER , �Y. / LG- m� ALJ CO. IMP. NO. JOB NO. � COMPENSATION INSURANCE ' } MAIL C .�n {'A� (This section need not be completed if the QQwork involved ADDRESS 7&o .S� S,4- , �7/JT/ r I/�C Lir TRUNK PERMIT NO. ROAD PERMIT NO. O by the permit is for one hundred dollars ($100) of less.) ��z / AFFIDAVIT WAIVER EASEMENT RECORD, INSTR, NO. DATE U ' CITY TEL. NO. i/-O(� 1/ I certify that in the performance of the work for which this LEGAL permit is issued,,l shall not employ any person in any manner DESCRIPTION LOT NO. 8:'Z— �'3 �� .111. OR ST. WIDENING so as to become subject to the Workers' Compensation Laws. f� •�7� _-. U BLOCK TRACT Z STATE ENCROACHMENT tL PERMIT NO. Date Applicant No. of BLD s. � NOTICE TO APPLICANT: If, after making this Certificate of slzE of Lor Now ON LOT z Exemption, you should become subject to the Workers' USE OFBUILDINGS CHARGES Compensation provisions of the Labor Code, you must forth- with comply with Such provisions or this permit shall be CONNECTION CHARGE FEE deemed revoked. CONTRACTORRJ, ' LICENSED CONTRACTORS DECLARATION CSC} S- 9� / REIMBURSEMENT FEE ADDRESS •J f'IY�J/'/{(� �t�� I hereby affirm that I am licensed under provisions of Chapter < /` /] DISTRICT NO. GROUP MAP PRo ESS 9 (commED By encing with Section 7000) of Division 3 of the Busi-_ CITY F-J• `�/ (�' /'CC TEL. NO./��j��Z BK PG l ,ness and Professions ode, and my license is in full force and STATE / -�'1 „-7 Llc. / �✓ /- LICENSE NO. YN CLA SSCP'e✓1i�'•`'�^ S �� /� effect. NO. DESCRIPTION OF WORK FEE 7( n �( / HOUSE SEWER CONNECTING TO FINAL a VALIDATION License Number" `—� LIc.Class C'���f�r_ PUBLIC SEWER DATE / `/� SEPTIC TANK,SEEPAGE PIT OR `�/�• �tZtC t_ Date I I~I��/ n PITS AND/OR DRAINFIELD FINAL 'Contractor PRI A SEWER CONNECTING TO BY OPRIVATE DISPOSAL SYSTEM I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR (Q licensed architect or a registered professional engineer WORK TO HOUSE SEWER 7/I acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD iness and Professions Code)• d' EXTN.,CESSPOOL,DRYWELL,MANHOLE 37 ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION z 1 9 3 A I hereby affirm that I am exempt from the Contractor's OWNER$ LPerrnit S # o'b DID 1 o License Law for the following reason (Section 7031.5, Busi- AUTHORIZATIONOTAL FEE ness and Professions Code): 2 po b 18.00 1 HAVE AT THIS DATE A CONTRACT WITH THE ER NAMED CON- ❑ TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING [, as owner of the property, will do the work and the To THE PUBLIC SEWER. `o'D o 1 8,0 0 structure is not intended or offered for sale (Section SIGNED THISL DAY OF 19_ 7044, Business and Professions Code). OWNER OR 1, 1 3-8 1 OWNERS AGENT I CONSTRUCTION LENDING AGENCY ADDRESS I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). 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 law's regulating Plumbing and Sewers, anI her by authorize representatives of this County to enter upon t e above-mentione pr erty for inspection purposes. to-2/ � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 808 (D2-80) A P P U C AT I O v FOR P E° ` W T I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL I 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. Cor�p ny C- —S7- 3 FOR APPLICANTTO FILL IN L�-�— CONNECTION DATA Certified,copy is hereby furnished. BUILDING Gi � � STATION _p . i6'rll DEPTH i ' E Certified copy is filed with the county building inspection ADDRESS J C fT CW" / ar deptment. ��� �C C MANHOLE REFERENCE `\ % � LOCALITY trBqK£R Date I(--13•-i-I Applicants NEAREST ` TYPE OF CONNECTION LENGTH FROM ll CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. y Y. CURB P.L. M.L. TO P.L. COMPENSATION INSURANCE P.C. NO. „ OWNER /L moi- CO. IMP. NO. JOB NO. MAIL / d (This section need not be completed if'the work involved ADDRESS { {'{ PP` TRUNK PERMIT NO. ROAD PERMIT NO. O by the permit is for one hundred dollars ($IOD) or less-) \} AFFIDAVIT WAIVER EASEMENT RECORD- INSTR, NO- DATE U C ITY� L jj/t(� TEL. NO. f/'Z/ I certify that in the performance of the work for which this LEGAL iF tY permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. "T—JHWY. OR ST. WIDENING O so as to become subject to the Workers' Compensation Laws. �i U BLOCK TRACT 12 r STATE ENCROACHMENT W Date Applicant NO. OF BLDGS. PERMIT NO. CL SIZE OF LOT - NOW ON LOT U) NOTICE TO APPLICANT: If, after making this Certificate of Z Exemption, you should become subject to the Workers' USE OF CHARGES - Compensation provisions of the Labor Code, you must forth- BUILDINGS with comply with such provisions or this permit shall be CONTRACTOR .�1 r . '� �IZ(C lC. � CONNECTION CHARGE FEE deemed_revoked. G-' SC / /� �J REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS ,n,.{ �.F�/�/�/, // GGL( I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP MAP PRo ESSED BY 9 (commencing with Section 7000) of Division 3 of the Busi- STATECITY �.LjJ ��{TEL. No. C. w 7 7�/� y� BK PG , ness and Professions Code, and my license is in full force and LICENSE No. w7 CLASS e�til 1 Ot (J� 3 effect- /� / NO. DESCRIPTION OF WORK FEE / f (/_J1y�A / HOUSE SEWER CONNECTING TO FINAL —/^ 2?(� VALIDATION License Number 66�( 10 Lic.Class (f C �✓�/ PUBLIC SEWER DATE �/ ,/ // G SEPTIC TANK,SEEPAGE PIT OR Contractor---r.Contractor .CY• ff�lLtc a Date I(���Q / PITS ANO/OR DRAINFIELD FINAL HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM F-1 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 r acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD iness and Professions Code). EXTN.,CESSPOOL,DRYWELL,MANHOLE 3-7 ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION I hereby affirm that l am exempt from the Contractor's OWNER'S Permit S AUTHORIZATION License Law for the following reason (Section 7031.5, Busi- TOTAL FEE Fz 1 9.5,2 A ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- 1. RACTOR O CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ElI, as owner of the property, will do the work and the TO THE PUBLITC SEWER. #•0'6,0 0 1,0; structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19` 7044, Business and Professions Code). OWNER OR OWNERS AGENT 2 D D 1 8,0 CONSTRUCTION LENDING AGENCY 0 0 0 1 8,0 0 I hereby affirm that there is a construction lending agency ADDRESS o for the performance of the work for which this permit is issued (Sec. 3097,Civ.C.). 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 t e above-mentioongdJproperty for inspection purposes. ©--Z I SEE REVERSE FOR EXPLANATORY LANGUAGE - Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CEA808 ( 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 �✓ BUI LDING AND SAFETY Policy No. Comp ny �— � � FOR APPLICANT TO FILL IN f•-2-_3 CONNECTION DATA Certified copy is hereby furnished. BUILDING % / STATION / DEPTH I Certified copy is filed with the county building inspection ADDRESS l (� �ir�/S /Q - de artment. / J�I �% /f/ MANHOLE REFERENCE P' �/ LOCALITY f s� Date L��'� Applicant�1 LOWER NEAREST TYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss sT. f '2L t,5 4 - 4-0 " Y. CURB P.L. M.L. TO P.L. COMPENSATION INSURANCE OWNER /�/ PZ/ CQ P.0 CO. IMP. NO. JOB. NO. NO. MAIL (This section need not be completed if the work involved ADDRESS J.1-%J 4.rTRUNK PERMIT NO. ROAD PERMIT NO. O by the permit is for one hundred dollars ($100) or less.) CIT 6' ✓'`'� ` ! AFFIDAVIT WAIVER EASEMENT RECORD. INSTR, NO. DATE U LTE L. NO.-/_ / ` S 1 certify that in the performance of the work for which this LEGAL tY- permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. Z� ?j "�" T HWY. OR ST. WIDENING O so as to become subject to the Workers' Compensation Laws. "- 2- V BLOCK TRACT 1 --77—, < ��, e� STATE ENCROACHMENT_-_ _ _ _ - _ _ _, _W PERMIT NO. _.. _ _:.. a Date Applicant NO.`OF BLDGS. • r4 NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF LOT NOW ON LOT , Z USE OF Exemption, you should become' subject to the Workers' CHARGES Compensation provisions of the Labor Code, you must forth- BUILDINGS with comply with such provisions or this permit- shall be CONTRACTOR` •'� �`� CONNECTION CHARGE FEE deemed revoked. d REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I am licensed under provisions of Chapter / DISTRICT NO. ::� BK MAP PG PROCESSED BY 9 (commencing with Section 7000) of Division 3 of the Busi- CITY<� (7ri j.,y/y TEL. NO.�-" Kness and Professions Code, and my license is in full force and STATL CENSE No. `€ � LI C.SS�e-.�;. � h -d�n� effect. NO. DESCRIPTION OF WORK FEE "��,. ��. HOUSE SEWER CONNECTING TO FINAL ` •p� VALIDATION . License Number IS c-1 LIc.Class PUBLIC SEWER DATE �L SEPTIC TANK,SEEPAGE PIT OR %/ /3F S'/ PITS AND/OR DRAINFIELD FINAL Contractors JL! Date HOUSE SEWER CONNECTING TO � BY +' PRIVATE DISPOSAL SYSTEM I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR J licensed architect or a registered professional engineer WORK TO HOUSE SEWER L[' acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD V/1 EXTN.,,CESSPOOL, DRYWELL,MANHOLE In CSS and Professions Code). ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lie,or Reg.No. Date HOME OWNER-BUILDER DECLARATION I'hereby affirm that I am exempt from the Contractor's OWNER'SPermit 8 License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE ness and Professions.Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- z' .1 �' 1 A 11 TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I, as owner of the property, will do the work and the TO THE PUBLIC SEWER. O .O O O 12 0: structureis not intended or offered for sale (Section SIGNED THIS DAY of ts_ 7044, Business and Professions Code). . OWNER OR 2 0°0 1 8.0 0 OWNERS AGENT ' CONSTRUCTION LENDING AGENCY ADDRESS 10 0'0 I hereby affirm that there is a construction lending agency 1 8. 0 0;5= for the performance of the work for which this permit is 1, 1 7J—8 1 issued(Sec. 3097,Civ.C.). 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 h e above-mentioned operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date