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HomeMy Public PortalAbout4523 ELLIS LN_Sewer__ WORKERS'COMPENSATION DECLARATION a I•h?reby.'a#firm that I have a certificate of consent to self. 92-0002 DPW 3/87 insure, or a certificate of Workers'Compensation Insurance, or 76A642D a certified co CE 808 thereof Sec. 3800, Lab C. 0 0 0 0 0 Policy No��,2�Company �ri ©_ . appd��Q�DOO �1 FOR pC Gv� ElCertified copy is hereby furnished. SEWER. SEWAGE DOSPOSAL ❑ Certified copy is filed with the county building inspection _ COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date�pplicant lG��;l`L /.tier FOR APPLICANT TO FILL IN CONNECTION DATA CERTI KATE 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 NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for,which this CROSS ST. Y. CURB P.L. _. M.L.TO P.L. permit is issued, 1 shall not employ any person in any manner subject to the Workers' Compensation Laws. ; P.C.NO. sous to become sub I P OWNER �/ CO.IMP.NO, JOB NO: MAIL TRUNK PERMIT NO. ROAD PERMIT NO, Date Applicant ADDRESS C NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE 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.CIgSS `��_ F REIMBURSEMENT FEE a ADDRESS p�, 0 Contractor �7LIV Date / ��77 DISTRICT NO. GROUP MAP PROCESSED BY 0 CITY TEL. / y _ BK PG STATE Z ❑ I am exempt under Sec. of the I.Co. LICENSE NO. CLASS H ' U Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE VALIDATION LU IL FINAL B. & P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR `�`� Z PITS AND/OR DRAINFIELD FI Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature - CONNECT ADDITIONAL BLDG.OR D 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 fessions Code): SEWS OR DISPOSAL SYSTEM r:V,;;r: M' ❑ I,as owner of the property,or m em to ees with wages as P P Y Y P Y 9 their 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 $ ^ El 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE -t licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO " Business and Professions Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. ..-i i .`.:€� `-1i-•'�'-'•• CONSTRUCTION LENDING AGENCY SIGNED THIS DAY OF 19 I hereby affirm that there is a construction lending agency D for the performance of the work for which this ermit is OWNER OR P P OWNERS AGEN issued (Sec. 3097, Civ. C.). ADDRESS G =*"''''': d i+P. Lender's Name %�.: Lender's Address 1 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. ;gnato Permitf a SEE REVERSE FOR EXPLANATORY LANGUAGE I/ORKERS'COMPENSATION DECLARATION I"'h~areby affirm that I have a certificate of consent to self 92-0002 DPW 3/87 insure, or a certificate of Workers'Compensation In urance, or CE 808 D CE 808 APPLOC�G LIMN FOR pC�aG� U a certified copy thereof (Sec. 3800, La .) p o o p o 0 0 Policy NoI_A���6�.�ompany ©s . ❑,—,�Certified copy is hereby furnished. ����� ����'�� ®��pO��� L�t'Certified copy is filed with the county building ins ction COUNTY OF LOS ANGELES BUILDING AND SAFETY department. �� Dote$7—/—!F2- Applicant �wls`Q FOR APPLICANT TO.FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERf, BUILDING J �+ ZW COMPENSATION INSURANCE ADDREss G-Zjy\ STATION DEPTH (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 7 r LOWER NEAREST ,vy / TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. �y G VG' 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. �_y P.C.NO. I P OWNER J f'/r�v 1 CO.IMP.NO, JOB NO. MAIL Date- Applicant ADDRESSyu:z J/� ��� TRUNK PERMIT NO. ROAD PERMIT NO.- CITY %p�� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of 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 N BLDGS. PERMIT NO. SIZE OF LOT NOW OLOT 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 Q effect. CONTRACTOR // /1 , 7� CONNECTION CHARGE FEE �3 0. 0. Livens u ber .Class REIMBURSEMENT FEE er 0 ADDRESS Ca nir ct40 '7— q >A DISTRICT NO. GROUP MAP PROCESSED BY V CITY, / _ TEL.NO.(71 l'� BK PG L Z ❑ I am exempt under Sec. of the L.A.Co. STATE uC. 0 P LICENSE NO. CLASS j, Lam" �_' NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the FINAL w HOUSE SEWER CONNECTING TO DATE VALIDATION B. & P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD — Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR - D 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 t fessions Code): SEWER OR DISPOSAL SYSTEM , ❑ I,as owner of the property,or my employees with wages as their 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 $ j ❑ I, as owner of the property, am exclusively contracting with' AUTHORIZATION TOTAL FEE licensed contractors to construct the project Section'7044, -� P I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO r` ' Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. �'':-i'[�'» r'•; CONSTRUCTION LENDING AGENCY _. SIGNED THIS DAY OF .19— for I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is OWNER OR issued (Sec.,3097, Civ. C.). OWNERS AGENT y ;31+i Lender's Name ADDRESS tJ;. .. 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 represe tatives of this County to enter u n 1 eabove-menoned pert y or inspection purposes. Si azure of Permi}tite Date SEE REVERSE FOR EXPLANATORY LANGUAGE