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Home My Public Portal About9849 FLAHERTY ST_Sewer__ WORKERS' COMPENSATION DECLARATION 20-0051 DPW 6189 1 hereby gffirm that I hose a cerAficole of consent to self Insure, or a certffl'cat6'of Workers' Compensation Insurance, or 76A642D o certified copy thereof (Sec Lob C ) APPLICATION FOR PERMIT Policy No. Companyny 0 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 Dote Applicant =FCIR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING Q COMPENSATION INSURANCE ADDRESS S STATION O' 1 DEPTH (This section need not be completed If the work Involved by the �� / PPE LOCALITY MANHOLE REFERENCE • LOWER permit Is for one hundred dollars ($100)or less ) - NEAREST 0/ ?l� �/ TYPE OF CO ION LENGTH FROM I certify that d the performance of the work for which this CROSS ST LI�/�/l J\ Y cuRB P L M L To P 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 Date Applicant BLOCK - TRACT TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT If, offer making this Certificate Of ASSESSOR a Q ��j AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE g MAP BOOK = !J PAGE GAS PARCEL �I 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 WIDFNING 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 OWNERPIFARL WL.1 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL ness and Professions Code, and m,/ license is In full force and ADDRESS SOX . )5 7 1 CHARGES effect CITY ITEM L CI TEL NO(09) 3 3 CONNECTION CHARGE FEE License Number LIC Class CONTRACTOR REIMBURSEMENT FEE Contractor Date DISTRICT NO GROUP MAP PROCESSED BY ADDRESS I am exempt under Sec of the L A Co l—4d �14 BK PG� Q� s�� a CITY TEL NO \.i o G�G�LLLQQ•-sem � Plumbing Code and/or Sec of the STATE LIC FINAL U LICENSE NO CLASS DATE /J`eZ VALIDATION Z B & P Code for the following reason NO DESCRIPTION OF WORK FEE O HOUSE SEWER CONNECTING TO FINAL H Date PUBLIC SEWER BY V SEPTIC TANK SEEPAGE PIT OR W PITS AND ORd�DRAINFIELD Signature HOUSE SEWER CONNECTING TO o OWNER-BUILDER DECLARATION PRIVATE 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 j fessions Code) OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL, DRYWELL,MANHOLE 1_ n ° E:1 1, REPAIR OR ABANDON HOUSE I, as owner of the property, or my employees with wages a5 SEWER OR DISPOSAL SYSTEM their sole compensation, will do the work and the structure s not Intended or offered for sale (Section 7044, Business Ly and Professions Code) ,_ 3 [N+L,_ 1, as owner of the property, am exclusively contracting with � licensed contractors to construct the project (Section 7044, OWNER'S Permit $ �'� 5/�� if'1HL _ -'�a - 35 Business and Professions Code) AUTHORIZATION TOTAL FEE 3 v: "• i. ow` 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 +I' '" CONNECT THE ABOVE DESCRIBED EXISTING DWELLING i0 THE PUBLIC SEWER ® H1.L_ v_t_ for the performance of the work for which this permit is issued (Sec 3097, Civ C ) SIGNED THIS DAY OF 19 OWNER OR i t-1`'0 o Lender's Name OWNERS AGENT CI'(}'0. ' 1 - f i- Lender's Address 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 laws regulciting Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned roperty for Inspection purposes Sign ure of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE YDEEA1tf ENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1 DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES BUILDING WILLIAM J. FOX, COUNTY ENGINEER_ ! ADDRESS FOR,APPLICANT TO FILL IN LOCALITY Z, C,BUILDING t' -ADESS '� , � j% t' CROSS ST. Z , I DISTRICT N0. SERIAL NO. PERMIT NO. LOCALITY A S NEAREST / �� f�l(� CROSS ST. �I RECEIVED B Ready for Inspection 9DAT ISSUED OWNER �0 -Z Me", eael MAIL USE ZO-E OCCUPANCY r ADDRESS So -"e, BK PG CITY TEL.NO. /eEFIS CONTRACTOR6 CO.IMP.NO. S,3 3 ADDRESS �O 0,d;rJ h JOB NO. CIT �, TEL.NNOO..i � / TRUNK PERMIT NO. REGISTRATION NO. / pfc- O COUNTY ROAD PERMIT NO. LEGAL STATE ENCROACHMENT DESCRIPTION LOT NO. PERMIT NO. BLOCK TRACT / `7�Q 3 INDUSTRIAL WASTE APPROVAL SIZE OF LOTNO.OF BLDGS. NOW ON LOT CHARGES USE OF BUILDINGS .J /�j@� CONNECTION CHARGE FEE NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TOREIMBURSEMENT FEE PUBLICSEWER @ $ 3.50 �SSO RECEIPT NO. DATE I BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDS.OR EXCEPTION RECORDED _WORK TO HOUSE SEWER 1.00 ALTER OR REPAIR EXISTING NO I DATE I BY _SEWER OR DISPOSAL SYSTEM 1.00 DISCONNECT AND ABANDON SEWER AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA — SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD 2.00 STATION . DEPTH 6 CESSPOOL—DRYWELL 8PECIAL CONDITIONS ONLY 2.00 1 2 4 / /,ten PP EFERENCEv & -L-OWE-M TYPE OF CTION LENGTH FROM OWNERS PERMIT $ I 00 sy?� cuR5 M.L.TO P.L. 3 AUTHORIZATION I TOTAL FEE -57 150 1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE DWELLING TO THE//P�UBLIC SEWER ��1 / SIGNED THIS____lC�•A --DAY OF.....l6`0 ...._..___..19.��+3 NEW HOUSE SEWER �r C. yjp—z� OWNER OR CONNECT ADDITIONAL OWNERS 'AGENT-__- .._._-4 BUILDING OR WORK ee ADDRESS_-..... �-----•-----/ / SEPTIC TANK.SEEP.PIT(S) �•••---••• AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL F] DRYWELL 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 I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND DISCONNECT PLUG AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ER OF THE ABOVE TRIBED RES TIAL PROPERTY. BACKFILL SEPTIC TANKS rr c SIGNATURE �Gr /!'� SEEP.PIT(S)E] CESSPOOLS[;?- 0 ESSPOOLS[;?- OF PERMITTEE_-_ __.. 76A642A 663 7/53 O, e�,�►y O