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Home My Public Portal About5324 FRATUS DR_Sewer__ i/ 4�4 iLRS' COMPENSATION DECLARATION J'.V -affirm that I ISVve a certificate of consent to self irtsure, or a certificate of Workers'Compensation Insurance, or 76A642D a certijigJgopq thereof (Sec 3800, Lab C ) CE 808(REV 8/81) Policy No%�OS`Z.S yCompany sf � �f ©5 APPLICATION FOR PERMIT ❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county,bullding Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department Date //-/3-.F7 Applicant J/� �p^-► 41,4NA!i FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS S 3 z �{ 3 , 1"),S (This section need not be completed if the'work Involved by the LOCALITY MANHOLE REFERENCE , L permit Is for one hundred dollars ($100)or less ) 6 WE T NEAREST TYPE OF CONNECTION LENGTH FROM I certify that In the performance of the work for which this CROSS ST Y CURB P LT) ML TOP L permit Is issued, I shall not employ any person In any manner so as to become subject to the Workers'Compensation Laws / P c NO OWNER ES tG'o r�f¢/'� CO IMP NO JOB NO MAIL i)O O J u� D�J I TRUNK PERMIT NO ROAD PERMIT NO Date/l"/3-Z7 Applicant J /wL oitil I¢/ff/✓/t/r ADDRESS [/ NOTICE TO APPLICANT If, after makingthis Certificate Of / p AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE CITY �R't C-,/- TEL N�� IJ& (p•3 6- 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 DECLARATIONNo OF BLDGS PERMIT NO I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT USE OF , ILI S, 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 CONNECTION CHARGE FEE ,� CONTRACTOR J�/'1il O yq `/-///wp/ License Number �25T�4-�Llc Class IL IL ADDRESS PO.�bl� /��/� REIMBURSEMENT FEE 0 Contrcctorji,+ C olN/flro A/AJ/ -Date i/�/�-3 - - '/ G� O CITY - „g,,,,,� - TEL NOS /��?"_� -/G Y L� DISTRICT NO GROUP MAP PR �IE V ❑ I am exempt under Sec of the L A Co' STATE LICCL r V ](_ LK r ,1G O p LICENSE NO p`Z,} o,2. �} CLASS '� J1 /U 0 Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE V FINAL � HOUSE SEWER CONNECTING TOATE VALID�L B & P Code for the following reason PUBLIC SEWER (f / �11 9 A y SEPTIC TANK SEEPAGE PIT OR Date��-�3-�� PITS AND/OR DRAINFIELD L # O O 0,0 10 HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature '� -! CONNECT ADDITIONAL BLDG OR WNER-BUILDER DECLARATION WORK TO HOUSE SEWER 2 7, 5 OVERFLOW SEEPAGE PIT DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN CESSPOOL DRYWELL MANHOLE O o 0 2 7.5 V Law for the following reason (SecTon 7031 5, Buisness and Pro- ALTER REPAIR OR ABANDON HOUSE p 0 fessions Code) SEWER OR DISPOSAL SYSTEM 1,�1 d 8 3 / ❑ j, as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure Is not Intended or offered for sale (Section 7044, Business and Professions Code) OWNER'S Permit $ ` ❑ j,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 TO Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCY , I hereby affirm that there Is a construction lending agency SIGNED THIS DAY r— - 19 OWNER OR J for the performance of the work for which this permit is OWNERS AGENT Issued (Sec 3097, Civ C ) �( ADDRESS Lender's Name L'ender'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 laws regulating Plumbing and Sewers, and hereb authorize representatives of this County to enter upon Ttheove-mentioned Ty for inspection purposes gnature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE