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Home My Public Portal About5020 ENCINITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION `f herebo affirm that I have a certificate of consent to self iasure, or-b certificate of Workers'Compensation Insurance, or 76A642D Fified copy thereof (Sec. 3800, Lab C.) CE808(REV.1/83) APPLICATION FOR PERMIT No. Companyertified copy is hereby furnished. _ SEWER - SEWAGE DISPOSAL ❑ Certifie cop is filed with t county b ns ection COUNTY OF LOS ANGELES BUILDING AND SAFETY de r t Date ppli nt FOR APPLIC TO FIL�IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKEVd BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS This section need not be completed if the work inv the UPPER ( P Y MANHOLE REFERENCE"' permit is for one hundred dollars ($100)or less.) LOCALITY Lowen NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. CURB P.I. 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. P.C.NO. I f OWNER CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS / e ^ AFFIDAVIT WAIVER EASEMENT RECORD.-INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of TEL.N s (J 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 NO.OF BLDGS. PERMIT NO. LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON L T 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, CIV my license is in full force an effect. CONTRACTOR CONNECTION CHARGE FEE License Num r Lic.Class / ADDRESS • 'REIMBURSEMENT FEE COr1Tra Cid ate • ry DISTRICT NO. GROUP MAP PROCESSED BY 0 CITY L.NO. 6 BK PG ❑ I am exempt under Sec. o the L.A.Co. STATE CL �( C°g P LICENSE NO. CLASS D Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL 4 HOUSE SEWER CONNECTING TO DATE VALID ION PUBLIC SEWER \ v B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT ORaspin PITS AND/OR DRAINFIELD FINAL Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG. OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DR NIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYW MAFNHO (Q� Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABA US �#ry} fessions Code): SEWER OR DISPOSAL ST I 0 1 S ❑ I,as owner of the property,or my employees with wages as q 0 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 S ❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the.project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAAD CONTR TO TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWEIII G To LIC SE R. CONSTRUCTION LENDING AGENCY , I hereby affirm that there is a construction lending agency SIGNED THIS D F 19 for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGEN • ADDRESS Lender's Name 1 Idi Lender's Address I certify that I read this application5-n d ate that e above inform correct. I agree t th all unty ordinances St laws regul 'n an ewers, and here Lit r' represe s ou y to enter upon t o - ned p or I c'knoilfoSes Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION +i heheb`q affirm that I have a certificate of consent to self jl ip,sui'e, or4a certificate of Workers'Compensation Insurance, or 76A642D U a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.1/83) APPLICATION FOR PERMIT Policy No. Company LJ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building 5pen COUNTY OF LOS ANGELES BUILDING AND SAFETY depart nt. r 'Date�JApplican A FOR APPLICANT T`O FILL IN �+ CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERBUILDINGADDRESS (�//Y/ STATION , 71 DEPTH COMPENSATION INSURANCE U UPPER (This section need not be completed if the work involved by the LOCALITY ��• MANHOLE REFERENCE OWER permit is for one hundred dollars ($100)or less.) NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST�� -� Y. CURB P.I. 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 • CO.IMP.NO. JOB NO. MAIL �`-� TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS ..�J NOTICE TO APPLICANT: If, after making this Certificate of CI TEL O. /6777V ER EASEMENT RECORD.INSiR.NO. DATE 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 f i PERMIT NO. NO.OF BIDGS. I LICENSED CONTRACTORS DECLARATION s1zE of Lor NO, F B Lor I hereby affirm that I am licensed under provisions of Chapter USE OF � J 9 (commencing with Section 7000) of Division 3 of the Bust- BUILDINGS A4et� & - CHARGES ness and Professions Code, d my license is in full force and B et � effect. CONTRACTOR • V CONNECTION CHARGE FEE License NU24., i Lic.Class ADDRES--7— Zt1A AV,'1L. REIMBURSEMENT FEE g, Coniracta( v Date ®�� AL r DISTRICT NO. GROUP MAP PROC SSED BY CITY ,I EL.NO. ® BK PG 0 STATE l L ❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO, stns �� O G/n Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL O -HOUSE SEWER CONNECTING TO ��') DATE/2_6/ VALID ON PUBLIC SEWER B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINA PITS AND/OR DRAINFIELD (In Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR poll 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 ' EJ 1,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 �3 5 a 5 A and Professions Code). OWNERS Permit $ Sv 0 0 0 0!10 ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE 7 D licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED Cg&TRACTOR TO O o27,50 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO HE PUBLJK SEVi$. CONSTRUCTION LENDING AGENCY 0 0 0 2 7,5 0 I hereby affirm that there is a construction lending agency SIGNED THIS DA OF , for the performance of the work for which this permit is OWNER OR 2 03-8 5 issued (Sec. 3097, Civ. C.). OWNERS AGENT�$� ®� Lender's Name ADDRES 04 Lender's Address I certify that I have read this application an state that the above information is correct. 1 agree t com y with all ounty ordinances and State laws regulatin PI bing and ewers, and hereb authorize repr niativ this County o enter upon ih ove-menti ed er o inspection p rposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE