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Home My Public Portal About5215 FARAGO AVE_Sewer__ WORKERS'COMPENSATION DECLARATION _ I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or (76A642D a certified c py, ereof (Sec.-3809, Lab C.) ry'� 92-0002 DPW 6/88 APPLICATION FOR PERMIT Policy No. � Company LF/2/h� .-r—�`E�' ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ] Certified copy is filed with a cou building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY . II� departm fent. tlJ Dote 1—T� 46 Applican VE_. FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM ORKERS' BUILDING a l� STATION DEPTH COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the LOCALP �� ! MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or less.) NEAREST NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. .��L� iv . 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 Gc L'rcP C CO.IMP.NO. JOB NO. MAIL /� / TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant IADDRESS/J(//�3— C L( U� 0Q-� NOTICE TO APPLICANT: If, after makingthis Certificate of wf AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY TEL.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 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 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. �1�I CONTRACT Z C_kW10� IFE CONNECTION CHARGE FEE License Number L -3 Lic.Class e—3J, ADDRESS /-v- REIMBURSEMENT FEE �^as'-�c� DISTRICT NO. GROUP MAP PROCE ED BY Contractor ,c O Date c - LIEt.No. - / �• �- STATE g LIC. / BK PG ❑ 1 am exempt under Sec. _Of the L.A.Co. LICENSE NO. ! ��/� CLASS C- )O ! +,(� O Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL / U HOUSE SEWER CONNECTING TO 01 DATE VALIDATION O F 0 B. 8 P. C Or following real n PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FINAL 1- PITS AND/OR DRAINFIELD ate HOUSE SEWER CONNECTING TO BY 0 PRIVATE DISPOSAL SYSTEM Lli� Signa ure CONNECT ADDITIONAL BLDG.OR ® Lf)�N R-BUILDER D LARATI N WORK TO HOUSE SEWER z OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm th t I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisnes5 and Pro- ALTER,REPAIR OR ABANDON HOUSE 10 fessions Code): SEWER OR DISPOSAL SYSTEM ACCT.y ❑ I,as owner of the property,or my employees with wages as 1"1`C 1 0 4 their sole compensation, will do the work and the structure 3307 34.50 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S. Permit $ _]:3 00 1 ITEMS ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE y --3n licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO TOTAL 4 .50 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. -/ C. CONSTRUCTION LENDING AGENCY iuELrYoV I herebyaffirm that there is a construction lending agency SIGNED THIS ` DAY OF 19_ CHANGE ffj 9 g Y OWNER OR GHANt�E aLll for the performance of the work for which this permit is OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS Lender's Name 00W AM Lender's Address U 1iy7 1 PLM 10 :i 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 r gu'ating Plumbing and Sewers, and hereby authorize repre entatives of this County to enter upol��e a Ove-m�tione perty for inspection purposes. ignature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION I hereby affirm that I hove a certifi4ate of consent to self. 92-0002 DPW 3/87 insure, or a certificate of Workers' mpensation I ce, Or -76A642D a certified copl�t r of (Sec. 38 ab,C.) CE 808 APPLICATION FOR PERMIT Policy No. ` � Company f e-� Os ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ^ertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM W RKERS' 7NEAREST ,� q 4 STATION DEPTH COMPENSATION INSURANCE /� V(This section need not be completed if the work involved by the /:P7 42 � _ MANHOLE REFERENCE UPPER LOWER permit is for one hundred dollars ($100) or less.) TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this Y. 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 7 LA 7/ c_C CO.IMP.NO. JOB NO. MAILDate Applicant ADDRESS -/ � , ,N� TRUNK PERMIT NO. ROAD PERMIT NO, AFFIDAVIT I WAIVER EASEMENT RECORD,INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CIT TEL.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 LICENSED CONTRACTORS DECLARATION NO.of PERMIT No. LOT SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDIN CHARGES ness and Professions Code, and my license is in full force and effect. 2(f,. CONTR �� CONNECTION CHARGE FEE Licenser Lic.Class �cJ K� REIMBURSEMENT FEE ADDR 0 DISTRICT NO. ROUP MAP PROCES D BY 0 Contract Date CIT TEL NO. �Q ` C� BK PG 7- ❑ lam exempt under Sec. of the L.A.Co. LICENSE NO.� DCLAS — b -/- aIV Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL � / HOUSE SEWER CONNECTING TOPUBLIC Se� /.'1, DATE VALIDAT ON o, EWER / C�' B. & P e for the following reason SEPTIC TANK,SEEPAGE PIT OR N PITS AND/OR DRAINFIELD FINAL A' ate HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM gn CONNECT ADDITIONAL BLDG.OR , WNER-BUILDER DECL RATION r 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 }} ❑ 1,as owner of the property,or my employees with wages as ACCT.s their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business 33307 34.50 and Professions Code). OWNERS Permit $ ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 5R^�, 5 ITEMS licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO }i[(�i tea .® � Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER, TOTAL CONSTRUCTION LENDING AGENCY C_�.ECY� 34.50 1 hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which this permit is OWNER :4NAK3E .00 issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS Lender's Name } -01} 1/26/9111 7 i6/ryt} Lender's Address I certify that I have read this application and state that the '3520 1 AM 10228 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 pon th JbOve-mentipef property for inspection purposes. Signature of Perm',tree Date SEE REVERSE FOR EXPLANATORY LANGUAGE