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Home My Public Portal About5835 ENCINITA AVE_Sewer__ WORKERS"CO*PENSATION DECLARATION - I hereby affirm that. 1 have a certificate of consent to self - insure,, *a certificate of Workers' Compensation Insurance, or TsnsaaD _ APPLICATION .a a^rtlfied copy thereof(Sec. 3800, Lab C.) 92.0002 DPW sive /�iPP�I�d`9 0 ®II C1 Ir®R PERMIT _ PppPool��liicy'No. Company CLICC �p� pu Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL /❑ Certified copy is filed with the county building pection COUNTY OF LOS ANGELES, BUILDING AND SAFETY IUB depa tme t. Date �ppIicant FOR APPLICANT TO FILL IN CONNECTION DATA C RTIF CATE OF EXEMPTION FROM WORKERS' BUILDING Jg 2s COMPENSATION INSURANCE ADDREss ✓ STATION DEPTH (This section need not be completed if the work involved by the tOCAUTMANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.), NEARESv _ LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this Cs",Si. - Y. CURB P.L. M .TO P.L. permit is issued, I shall not employ any person in any manner _ so as to become subject to the Workers a s Compe L . // P.C.NO. P � OWNER CO.IMP.NO. - l08 NOMAI . ADD TRUNK PERMIT NO. ROAD PERMIT NO. Datejz / Applicant � ADDRESS y- NOTICE TO APPLICANT: If, offer ma:trig 1) aIlticate Of CIT Iyt NO. '29 Z-9 AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO. DATE Exemption, you should become subject to the WorkersLEGAL 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 •ND.OF BIDGS. PERMIT NO, SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under or of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of,the Bu41- BUILDINGS CHARGES ness and Professions Cade, and my license is in full force and - effect. CONTRACTO .J CONNECTION CHARGE FEE License Number<61ic.Class ADDRESS REIMBURSEMENT FEE Controctor a DISTRICT NO �JpTOUP MAP 5ESSED By CITY iEL.NO. �/ ! ]EI /'-'L,// / / n BN PG /'I /� ❑ I am exempt rider Sec. of the L.A.Co. LICENSE NO, CL 1Lwf- (J.�.I/VI/V(1/ K J( J(Lf�(/_J } ..3 � nnss d O DESCRIPTION WO Plumbing Code and/2.r Sec. of the NO. RK FEE DATE CC HOUSE SEWER CONNECTING i0 /� DATE VALIDATION � B. 8 P. Code.for the following reason I PUBLIC SEWER —JJ0 O - SEPTIC TANK,5EEPAGE PIT OR O FINAL 0 Dote PITS AND/OR DRAINFIELD - HOUSE SEWER CONNECTING TO F.NAL W PRIVATE DISPOSAL SYSTEM d Signature CONNECT ADDITIONAL BLDG.OR (A OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER _..____.. _ ._.. .-.... Z OVERFLOW SEEPAGE PIT, — I hereby affirm that I am exempt from the Contractor's License ENTN.,CESSPOOL,DRYWELL,ELL.MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,RE DISOR POSAL OSABANDON HOUSE - 1D ' - -1• feSSionS Code): SYS . .ACCT.i_•- - ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure 3307 27.50 is not intended or offered for sole (Section 7044, Business //TT and Professions Code). OWNER'S Permit E V ., ._... . .._.... ..................._.....1.-ITEMS ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE Z.-7 TOTAL 27 .50 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE CONTRACT WITH HEREIN NAMED CONTRACTOR i0 LL p rr BUSIne55 and Professions Code). 'CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CHECK 27.)LI CONSTRUCTION LENDING AGENCY s _• SIGNED THIS DAY OF 19_ .._.... ..................�; . . _. -013I hereby affirm That there is o construction lending agency , for the performance of the work for which.this permit is OWNERNERS AGENT - OR issued (Sec. 3097, Civ. C.). _ Lender's Name ADDRESS 0000-0001 12/13/39 Lender's Address 7.503 1 AM11:33 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 represent Wks is County to enter U pon thea do I( inspection pur ses. ig ! re o r Date �� r SEE REVERSE FOR EXPLANATORY LANGUAGE DEPAK'rM(ENT OF COUNTY FNGINFFA -SEWER--SEWAGE DISPOSAL DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION L COUNTY OF LOS ANGELES UILNG WILLIAM J. FOX, COUNTY "GORES ENGINEER I AS ' FOR APPLICANT TO FILL IN LOCALITY BUILDING � ` 1 NEAREST ADDRESS / CROSS ST. LOCALITY lzl0. DISTRICT NO. SERIAL N0. PERMIT NO. NEAREST � v A /3 7 /0� rl75 CROSS ST. .� -,-��.� RECEIVED BY flondy for Inspection DATE ISSUED OWNER MAIL U/SEyOamNIf ADDRESS \ II` OCCUPANCY) AP CITU eqUA,11ELfN O. •l (1� CONTRACTOR �.,f.� CO.IMP.NO. ADDRESS JOB N0. CITY TEL-NO 1 I� TRUNK PERMIT N0. REGISTRATION N0. 7 d^J^J 1 � �_ ( _S9�C�D}!,0 Y ROAD PERMIT NO. •� 7 LEGAL ��CJ 0 STATE ENCROACHMENT DESCRIPTION LOT N0. �/.q PERMIT MO. BLOCK�� TRACT � M.fn I INDUSTRIAL WASTE APPROVAL SIZE OF LOT NO.OF SLOGS. NOW ON LOT CHARGES USE OF BUILDINGS CONNECTION CHARGE FEE NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE PUBLICSEWER @ $ 3.50 �; . RECEIPT NO. I DATE BY HOUSE SEWER CONNECTING TO - PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR. EXCEPTION RECORDED WORK TO HOUSE SEWER -- -' - 1.00 - - ALTER OR REPAIR EXISTING - NO' I DATE BY SEWER OR DISPOSAL SYSTEM ,1.00 1 DISCONNECT AND ABANDON SEWER AND/OR DISPOSAL SYSTE M 1.00 CONNECTION DATA SEPTICNK,SEEPAGE PIT OR / D�� — PITS ANDD/OR GRAINFIELD 2.00 STAT04f DEPTH 9 / CESSPOOL—DRYW ELL 6` SPECIAL CONDITIONS ONLY 2.00 1 /.' 0 o MANHOLEREFERENCEEFERENCE L SWER TYPE OF CONNECTIONn LENGTH FROM OWNERS PERMIT S I 00. Y. - CURB ' //P.Alf M.L.To P.L. AUTHORIZATION I TOTAL FEE V 1. 1HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED - CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER APPRO ALS -' INSPECTOR'S SIGNATURE GATE SIGNED THIS--------------------DAY OF----------------.................._19.___ NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT......._.._......_......_.........._--------------_------_._._. BUILDING OR WORK ESS---------------_------- SEPTIC TANK,SEEP.PIT($) ADDR ....._................._.............._..-----.._...-----._. AND/OR GRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI CESSPOOL 0 DRYWELL E] CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ) AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN. ABANDON HOUSE SEWER ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPEgTY. BACKFILL SEPTIC TANKS - SEEP.PIT(S)Q CESSPOOLS SIGNATURE / y OF PERMITTEE... --------- 26A842D 663 1/53 CYC