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Home My Public Portal About5229 FARAGO AVE_Sewer__ WORKERS' COMPENSATION DECLARATION DPW 6189 �p I hereby affirm that I hove a certificate of consent to self 270-0057 0-0051 insure, or 6,certificate of Workers' Compensation Insurance, or a Certified copy thereof Sec. 3$00, Lo III,Policy NoAPPLICATION FOR PERMIT /t/ Y_Qy�� G" M Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county buil i o COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date;jj— — Applicont FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING r srnTloN DEPTH COMPENSATION INSURANCE ADDRESS J (This section need not be completed if the work involved by the , I MANHOLE REFERENCE UPPER LOWER permit is for one hundred dollars ($100) or less.) LOCALITY NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CRosssT. r CURB a L M L TOP L permit is issued, 1 shall not employ any person in any manner LEGAL PC No so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO. co IMP NO JOB NO BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO Date Applicant NOTICE TO APPLICANT: If, after makingthis Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE IMAPBOOK PAGE PARCEL Exemption, you should become subject to the Workers' NO.OF BLDGS. / Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT Hwv OR 5T WIDENING comply with such provisions or this permit shall be deemed USE OF revoked. BUILDINGS STATE ENCROACHMENT PERMIT NO LICENSED CONTRACTORS DECLARATION ��- I hereby affirm that I am licensed under provisions of Chapter OWNER /L- 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL nooaEss 2.S �¢- CHARGES ness and Professions Code, and my license is in full force and effect. J✓P CITY O TEL.NO, CONNECTION CHARGE FEE License Number LIC. CIa55/v-C�� CONTRACTOR �� REIMBURSEMENT FEE�[�- Contractor W/ ate DISTRICT NO GROUP MAP PROC ED BY ADDRESS j� BK PG El am exempt under Sec. of the L.A.Co. s 0 O ' aL CITYEL.NO. O Plumbing Code and/or Sec. of the STATE LIC. FINAL 0 LICENSE NO. 7 CLASS iv DATE VALIDATION B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE `�3 ZO HOUSE SEWER CONNECTING TO FINAL Dote PUBLIC SEWER By 0 SEPTIC TANK SEEPAGE PIT OR W Signature PITS AND OR DRAINFIELD d OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM , Z I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR Law for the following reason (Secton 7031.5, BuisneSs and Pro- WORK TO HOUSE SEWER feSSIOnS Code): OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN,CESSPOOL.DRVWELL.MANHOLE ACCT UT E] 1, REPAIR OR ABANDON HOUSE ACC I I, as owner of the property, or my employees with wages as SEWER OR DISPOSAL SYSTEM their sole compensation, will do the work and the structure �; � Jec` is not intended or offered for sole (Section 7044, Business and Professions Code). 1 ITEMS ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, OWNER'S Permit $ ?, TOTAL 66 ffi 3 Business and Professions Code). AUTHORIZATION TOTAL FEE S (;�{��; �, CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CHANGE .01[1 for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19 OWNER OR �'l �jj10/301/92 (}J ,S ` Lender's Name OWNERS AGENT L04I3I3-0001 10 301/92 Lender's Address ADDRESS 6274 1 AN 9:06" 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 reg g um bing and Sewers, and here�ve- �ntiohed �roperTyor of this County to enter upon the inspection purposes. / i nature of Xrmittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION DPW 6/89 I hereby affirm that I have a certificate of consent to self 270-0057 0-0051 Insure, or o'certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. Lab C.) APPLICATION FOR PERMIT Policy No. Companyny ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified 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 WORKERS' BUILDING oiiv COMPENSATION INSURANCE ADDRESS �j60 STATION DEPTH (This section need not be completed if the work involved by the //_ MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100) or less.) LOCALITY C+C LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y CURB P L M L TO P L permit is issued, 1 shall not employ any person in any man er LEGAL PC NO so as to become subject to the Workers'"Compensation� La DESCRIPTION LOT NO. CO IMP NO JOB NO�y� ,�j BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO Date Applicant_ �[7 V ��v NOTICE TCI APPLICANT: If, after makin this Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE g MAPBOOK PAGE PARCEL Exemption, you should become subject to the Workers' NO.OFBLDGS. Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked. BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER [ 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL o Hess and Professions Code, and mV license is in full force and ADDRESS CHARGES effect. v� CONNECTION CHARGE FEE /�J�/ '1 CITY TEL.NO. License Num Lic. Class l/•� l� y REIMBURSEMENT FEE CONTRACTOR COntrocto -`r ,VDate r• 1e� DISTRICT NO GROUP MAP PROCESSED BY ADDRESS "J1 BK PG ❑ I am exempt under Sec. of the L.A.Co. -3--6 1(_ 73 3Q� `t GGG��ie� CITY El.N Plumbing Code a /or Sec. of rhe STATE LIC. FINAL 0 LICENSE NO. CLASS 0 DATE � VALIDATION Z B. 8 P. Code following reason NO. DESCRIPTION OF WORK FEE !� z HOUSE SEWER CONNECTING TO FINAL f r t Date PUBLIC SEWER BY V SEPTIC TANK SEEPAGE PIT OR Signature PITS AND OR DRAINFIELD - 1 X54 3 HOUSE SEWER CONNECTING TO OWN ER-B DER DECLARATION PRIVATE DISPOSAL SYSTEM ® i f ITEM I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER TOTAL ��- ® � fessions Code): OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN CESSPOOL,DRYWELL.MANHOLE ❑ I, as owner of the property, or my employees with wages as ALTER.REPAIR OR ABANDON HOUSE ti,;.ECK 154.01 their sole compensation, will do the work and the structure SEWER OR JISPOSAL SYSTEM is not intended or offered for sale (Section 7044, Business (':HANGE .00 and Professions Code). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, OWNER'S Permit $ 1 0000-0001 1/151"1 Ir r v Business and Professions Code). AUTHORIZATION TOTAL FEE O AM 9:29 CONSTRUCTION LENDING AGENCY I HAVE AT THIS DA CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO I hereby affirm that there is a construction lending agency CONNECT THE ABO DE CRIBED EXISTING D ING TO THE PUBLIC SEWER , for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). SIGNED THIS D F 9� i OWNER OR Lender's Name OWNERS AGENT Lender' ddress ADDRESS I ce Ify that I have read this application and state that the ab ve in rmation is correct. I agree to comply with all County o din es and State laws regulating Plumbing and Sewers, nd h eby outhor7ltrepresen atives of this County to enter MSi e above-m ned pr perry for inspection purposes. i otu amiitee Date SEE REVERSE FOR EXPLANATORY LANGUAGE