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Home My Public Portal About5341 ENCINITA AVE_Sewer__ W WORKERS'COMPENSATION DECLARA'i ION I hereby affirm that I have a certificate of con!C jit,t2:self 11 insure, or a certificate of Workers'Compensaticin V&trance,t)r,' —.eA642E-". I~., a certified copy thereof (Sec. 3800, Lab C. CEepalV ;831 APPLICATION FOR PERMIT Policy No. Company ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with the ty buildin 'nspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date//Applicant FOR APPLICANT TO FILL IN, CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING /� j STATION c� j� DEPTH l� COMPENSATION INSURANCE ADDRESS ! // (This section need not be completed if the work involved by the LOCALITY 1`2 MANHOLE REFERENCE ' f•ZY, �-5.30t N LOWER permit is for one hundred dollars ($100)or less.) NEAREST TYPE OF CONNECTION I certifythat in the performance of the work for which this LENGTH FROM p CROSS ST. 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. OWNER G �y P.C.NO. r L.� (� Q ��',/sI// C." (7 CO.IMP.NO. JOB NO. MAIL h TRUNK PERMIT NO. ROAD PERMIT NO. bsS Date Applicant ADDRESS (/ NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY � TEL.NO. •"12 �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 1 LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT ,+ �J I hereby affirm that I am licensed under provisions of Chapter USE OF r 7 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. J � /" CONTRACTOR L CONNECTION CHARGE FEE License Number / "LIC Class J[ -- Tc/ ADDRESS L REIMBURSEMENT FEE Contractor to�/� Z �D J DISTRICT ��O MAP PR ESSEDBY C6 CITY TEL.NO. '� / BK PG01 am exem t under Sec. of the L.A.Co. STATE /� CLLICP LICENSENO. p �/ CLA55 Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL 04HOUSE SEWER CONNECTING TO DATE VALIDATIO �' B. 6 P. Code for the following reason BLIC SEWER PU PTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL yy Date HOUSE SEWER CONNECTING TO BY , 7. PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR 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 Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ;2 10 2 9 A ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure # 0 0 0 0 1 is not intended or offered for sole (Section 7044, Business and Professions Code). OWNER'S Permit $ b a o 2 7,5 0 ❑ 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 NAMED CONTRACTOR TOo 7'S 0 5 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 2 IV CONSTRUCTION LENDING AGENCY �C ► 1,07-84 1 hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 11ZT for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT 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 lows regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the ve,mentio roperty for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION I hereby affirm that I hove a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D I a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.1/83) APPLICATION. FOR PERMIT Policy No. Company ElCertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with th county buil ' gg ion COUNTY OF LOS ANGELES BUILDING AND SAFETY de artment. Date ' Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM-WORKERS' BUILDING - STATION i' DEPTH COMPENSATION INSURANCE ADDRESS G sU (This section need not be completed if the work involved by the UPPER permit is for one hundred dollars ($100)Or less.) LOCALITY er MANHOL�REFERENCE LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROS3i,5T, C, 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. OWNER - CO.IMP.NO. P.C.NO. JOB NO. MAIL \ r /y� q/ l� TRUNK PERMIT NO. ROAD PERMIT NO, Date Applicant ADDRESS �J �✓ ✓! ' TO APPLICANT: If, after making this Certificate o{ 1 / AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE g CITY NOTICE1, EL.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 j LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. L7 SIZE OF LOT � NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USEof ci 9 (commencing with Section 7000) of Division 3 of the BUsi- BUILDINGS C� CHARGES ness and Professions Code, and my license is in full force and .,.�� effect. v�/i -J/ CONTRACTOR Y/Z\ 6N - CONNECTION CHARGE FEE License NL ber ' ` ic.Class J ADDRESS r REIMBURSEMENT FEE 96 (� DISTRICT NO. GROUP MAP PROCESSED BY O Contrac Date r CITY L TEL NO. / 4U STATE Z LIC. ``,, BK PG ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. \ cLAss V R ✓ NO. DESCRIPTION OF WORK FEE A��Ile- 0 PlumbingCode and/or Sec. ofthe FINAL U HOUSE SEWER CONNECTINS,TO DATE VALIDATI 8. & P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGFF//PIT OR PITS AND/OR DRAINYIELD FINAL Date HOUSE SEWER COttINECTING TO BY PRIVATE DISPOSAL SYSTEM \ . Signature CONNECT ADDIT ONAL BLDG.OR \ , OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER \ pp OVERFLOW SEEPAGE PIT,DRAINFIELD \ �'1 0 2 8 A 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,REJAIR OR ABANDON HOUSE \ #'O O O O 1 0 fessions Code): sEWE QR DISPOSAL Ykym ❑ I,as owner of the property,or my employees with wages as their sole compensation,will do the work and the structure �� J o.1 51L,00 is not intended or offered for sale (Section 7044, Business and Professions Code). WNER'S I Permit $ \ — o. a 154,005 ❑ I,as owner of the property,•om exclusively contracting with AfHORIZATION TOTAL FEE licensed contractors to construct the project (Section 7044, AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO I 1.0 I �8 4 Business and Professions Code). /CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER\��(jj CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, CIV. C.). OWNERS AGENT ADDRESS Lender's Name Lender's Address I certify that I have read this application and state that th above information is correct. I agree to comply with all Cou t'y ordinances and State laws regulating Plumbing and SeWs, and hereby authorize representatives of this County t"nter upon the ab . -mentione roperty for inspection purposes. Signature of Permittee tDate SEE REVERSE FOR EXPLANATORY LANGUAGE