The URL can be used to link to this page

Home My Public Portal About9160 EMPEROR AVE_Sewer__ . WORKERS'COMPENSATION DECLARATION CE 808 1:) 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 STATION DEPTH ® Certified copy is filed with the county building ins c ion ADDRESS / b . �// UPPER department — MANHOLE REFERENCE p LOCALITY �t LOWER Date 4 Applicant NEAREST TYPE OF CONNECTION LENGTH FROM ERTI KATE OF EXEMPTION FROM WORKERS' CROSS sr Y CURB P L M L TO P L COMPENSATION INSURANCE c rvo OWNER 14%4 ,�f1� CO IMP NO Q JOB NO } MAIL C 0. (This section need not be completed if the work involved MAI ADDRESS �'� TRUNK PERMIT NO ROAD PERMIT NO O G by the permit is for one hundred dollars (5100) or less) 49 V AFFIDAVIT WANER EASEMENT R CORD INSTR NO DATE CITY d .)J � 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 W r Compensatio aws 0 �/ • �' BLOCK TRACT STATE ENCROACH ENT �/ / Date! Applicant�.dE—� y NO OF BLDGS PERMIT NO 44 I d a NOTICET6APPLICANT If, after making this Certificate of sizE of Lor rvow ON Lor Exemption, you should become subject to the Workers' BSUI BUILDINGS B ?PLC-A--ES Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall beCONTRACTOR O �� /JiJ G CONNECTION ARGE FEE deemed revoked "` REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS e1 f I hereby affirm that I am licensed under provisions of ChapterDISTRICT NO GROUP BK MAP PG FROC SSED Bv- 9 (commencing with Section 7000) of Division 3 of the Busi crcYA� �' TEL rvo LIC _7 ness and Professions Code, and my license is in full force and STATE LICENSE No ai Ass G— effect NO DESCRIPT ON OF WORK FEE / / HOUSE SEWER CONNECTING TO FINAL �l J�� VALIDATION License Numb E'/s c Class PUBLIC SEWER DATE SEPTIC TANK,SEEPAGE PIT OR ' Contractor DatePITS AND/OR DRAINFIELD leeI FINALi 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, GRAINFIELD mess and Professions Code) EXTN ,CESSPOOL DRYWELL, MANHOLE ALTER, REPAIR OR ABANDON HOUSE SEWER gR DISPOSAL YSTEM Lic or Reg No Date HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNERS Permit S License Law for the following reason (Section 7031 5, Busi- AUTHORIZATION TOTAL FEE 1 3 0.6 A ness and Professions Code) 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- ❑ TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING # O r0 O O 54 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 SIGNED THIS v of 19�f 2 D - 40.00 7044, Business and Professions Code) OWNER OR OWNERS AGENT CONSTRUCTION LFNDING AGENCY ADDRESS D O D 4 0, 010 5 I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is /L ,�4 //� /� 0 9,23-81 issued (Sec 3097,Civ C) �( / 7 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 prop ty for inspection purposes a I SEE REVERSE FOR EXPLANATORY LANGUAGE 6' Ignature of Permittee D w�0 WORKERS'COMPENSATION DECLARATION `76A642CE 808 f92 80)v� 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 lY a certified copy thereof(Sec 3800 Lab C) �(N 9 COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company ❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA/ BUILDING STATION DEPTH / _ Certified copy is filed with the county building inspection ADDRESS O C!►' �L� UPPER department LOCALITY 1 MANHOLE REFERENCE LOWER Date Applicant NEAREST ✓ TYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss ST /J _ Y CURB P L M L TOP L COMPENSATION INSURANCEP C NO OWNER 11Zrzn CO IMP NO rJ JOB NO MAIL (This Section need not be completed if the work. involved ADDRESS CITY TEL NO TRUNK PERMIT NO OAD PERMIT d by the permit is for one hundred dollars ( 100) or_less) AFFIDAVIT WAVER EASEMENT RECORD INSTR NO DATE O i „Q V 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 0 so as to become subject to the kers' Compensation La BLOCK TRACT STATE ENCROACHMENT V PERMIT NO Date Applicant s� No of BLD GS W NOTI E T APPLICANT If, after making this Certificate of sizE of Lor Now ON Lor Exemption, you should become subject to the Workers' USE OF CHARGES Z Compensation provisions of the Labor Code, you must forth-, BUILDINGS _ with comply with such provisions or this permit shall be L CONNECTION CHARGE FEE deemed revoked CONTRACTOR DRESS REIMBURSEMENT FEE AD LICENSED CONTRACTORS DECLARATION w I hereby affirm that I am licensed under provisions of Chapter DISTRICT No GROUP MAP PROCESSED BY 9 (commencing with Section 7000) of Division 3 of the Busr clry TEL No BK PG ness and Professions Code, and my license is in full force and srA E LIC �?�/ 12of,�� effect LICENSE NO CLASS 1— NO DESCRIPTION OF OR K FEE /i� HOUSE SEWER CONN EGTING TO FINAL VALIDATION License Number Ic Class 7 PUBLIC SEWER DATE �r _ SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD /1 Contracto Date F I N A L ' , HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM F1 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 ;2 1 3 0,5 A ness and Professions Code) I HAVE AT THIS DATE A CONTRACT WITH THE HEREIA NAMED CON- ❑ TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING # O�O O'O 110 I, as owner of the property, will do the work and the TO THE PUBLIC SEWER y structure Is not intended or offered for sale (Section SIGNED THIS AY OF 19 / 2 D- 18.00 7044, Business and Professions Code) OWNER OR OWNERS AGE /fl� CONSTRUCTION L1 NDING AGLNCY AODREss a o 0 0 1 a O O c=i I hereby affirm that there is a construction lending agency for the performance of the'work for which this permit is 0 9,23781 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 the ab�eentioned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date 0001, o1 /