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HomeMy Public PortalAbout9015 EMPEROR AVE_Sewer__ WORKERS' COMPENSATION DECLARATION. T6 c� I•hereby affirm that I have a certificate of consent to self U insure, or a certificate of Workers'Compensation Insurance, or 26A642D ^ ! (J a certified copy thereof (Sec. 3800, Lob C.) / CE809IREV.1,89, APPLICATION FOR PERMIT Policy N Co�m► pany _ � SEWER - SEWAGE DISPOSAL ❑ Certified c s2by fYnishe �� ❑ Certified copy is filed with the county building inspection dl� 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 ADDRESSUPPER ` MANHOLE REFERENCE OWER (This section need not be completed if the work involved by the w LZ \ LOCALITY �- permit is for one hundred dollars ($LOO)Or less.) NEAREST ,y� TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. ®� 1L�1 ' yN.1Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner P.C.NO, so as to become subject to the Workers'Compensation Laws. OWNER { s CO.IMP.NO. JOB NO. MAIL v ADDRESS ��\ �� TRUNK-PERMIT NO. ROAD PERMIT NO.Z2 i Date Applicant NOTICE TO APPLICANT: If, after makingthis Certificate Of © 777 AIVER EASEMENT RECORD.INSTR.NO. DATE CITY Q vJ TEL.NO. 20 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 2— LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. C! SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE of �5� 2 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CDN CHARGES ness and Professions Code, and my license is in full force and 2 CONNECTION CHARGE FEE effect. CONTRACTOR License Number Lic.Class- ADDRESS REIMBURSEMENT FEE Contracto • +.>t�1 Cri, L---Date ! ��I e DISTRICT NO. GROUP MAP PR ESSED BY ' CITY TEL.NO. _ ��' BK - PG 0 STATE LIC. ���/ [ ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS �� try o 0 s` W qse Plumbing Code and/or Sec. of the NO. DESall ION W RK FEE O FINAL r -HOUSE DATEVALIDATION L" B. &P. Code for the following reason PUBLIC SEWER (/ CCC!!! ` SEPTIC TANK,SEEPAGE PIT OR FINAL 10' •� PITS AND/OR DRAINFIELD BY y Date ✓ S7 T HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM SignatureJT CONNECADDITIONAL BLDG.OR ► /j���O 40 WORK CT HOUSE SEWER / 1 OWNER-BUILDER DECLARATION 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 (Sectors 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 2 6 4 2 A fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property, or my employees with wages as 4 o 0 0 0 1 0 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business 27.5 0 and Professions Code). OWNER'S Permit c u 2 7 5 0 ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 1,?-7 ITO o licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO O ! 1 1 -8'4 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY " �u� 1 PooI.hereby affirm that there is a construction lending agency SIGNED THIS ` )DAY OF OWNER for the performance of the work for which this permit is OWNERSOAGENT 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 aev entioned property for inspection purposes. Z ignature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE 'WORKERS' COMPENSATION DECLARATION I.hereby affirm that I have a certificate of consent to self lI insure, or a certificate of Workers'Compensation Insurance, or 76A642D U ac�+r L p ereolSec. 3800, La�, CE 808(REV.1/83) APPLICATION FOR PERMIT PoRNo.� &3 0 7C�ompony Ta���-+ a,i ElCertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH ADDRESS PCOMPENSATION INSURANCE / V (This section need not be completed if the work involved by the _7 yi I MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY zc����L J T `. LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. 'L ' i✓/� i/' �L_ 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 LOWS. P.C.NO. I p OWNER � /� CO.IMP.NO. !OB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS Z �� � �% NOTICE TO APPLICANT: If, after makingthis Certificate of s / / AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITYtz w TEL.NO. k" 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 �q 9 (commencing with Section 7000) of Division 3 of the Busl- BUILDINGS 1Si GL��/y-!f�f(f CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE License Number LiC.Class ADDRESS eA6400e REIMBURSEMENT FEE Contractor Date DISTRICT NO. GROUP MAP PROCESSED B10Y CITY •� TEL.NO.7.- , _ ! BKPG El am exempt under Sec. of the L.A.Co. STATE uLAc. �� P LICENSE NO. CSS .' a7 NO. DESCRIPTION O WORK FEE F NAL p Plumbing Code and/Or Sec. Of the -HOUSE SEWER CONNECTING TO DATE •/ / VALIDATION PUBLIC SEWER B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT ORA. AND/OR DRAINFIELD BY AL PIR Date HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR Poo. 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, BuiSness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM -2264,3 A 's 1 El 1,as owner of the property,or my employees with wages as # o 0,0 0 0 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business Permit g 2'01- 40.0.0 and Professions Code). OWNERS El 1, FE I,as owner of the property, am exclusively contracting with AUTHORIZATION TE 0'0.o Lj U . r licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED NTR CTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER, 07.1 1 84 CONSTRUCTION LENDING AGENCY �C(e' , I hereby affirm that there is a construction lending agency SIGNED THIS / DAY OF l 19'- for the performance of the work for which this permit is OWNER A _ a P P OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS`" 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 above- ntioned property for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE