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HomeMy Public PortalAbout9517 GIDLEY ST_Sewer__ WOF.KERS;,COMPENSATION DECLARATION 1 he4,by Affirm That I have a certificate of consent to self insure,qr a certificate o Wo'rlser�Compensation Insurmhc4,'or's IIAIa D l� -a certif)gd copy thereof Sec. 3800, Lab C.) 92-0002 DPW 6/88 APPLICATION FOR PERMIT Pol jy Ns. Company ❑ 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 i {l STATION DEPTH COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the LOCALITY � .' CA MANHOLE GFERENCE permit is for one hundred dollars ($100)or less.) I certifythat in the performance Of the work for which this NEAREST / TYPE OF CON CTIO` LENGTH FROM P CROSS ST. � �/� Y. �g' M.L.TO P.L. permit is issued, I shall not empl any person in an manner P.0 NO. so as to become subject to the O ers COmpenSaT' Laws. OWNER CO IMP.NO. JOB NO MAIL 4 TRUNK PERMIT N ROAD PERMIT NO. DateApplicant -yya.�-v ADDRESS ff�� -ZD AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after maki g this Certificate of CITY TEL.NO. 1-7 V 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 �J revoked. BLOCK TRACT �C._ vy— STATE ENCROACHMENT NO.OF BLDGS. _ PERMIT NO. LICENSED CONTRACTORS DECLARATION SIZE OF LOT r Z�x 15 NOW ON LOT N �- I hereby affirm that I am licensed under provisions of Chapter TSE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS --I 7i CHARGES ness and Professions Code, and my license is in full force and effect CONTRACTOR '{ I N CONNECTION CHARGE FEE License Nu er 10 4q Lic.Class �7 j�� ADDRESS '"'� REIMBURSEMENT FEE COntraCtor 1� Date , �'—`r"b� DISTRICT NO. GROUP MAP PROCE DB CITY �� ,r TEL.NO. 0 SK PG } ❑ I am exempt under Sec. of the L.A.Co. LICENSE No. �. (r4 CLASs �� V CL O Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINALU PUBLIC SEWER HOUSE SEWER CONNECTING TO O DATE �`� . VALIDAT ON B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL O PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY L11 PRIVATE DISPOSAL SYSTEM ILSignature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER 1 M I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELD ZEXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): v5, SEWER OR DISPOSAL SYSTEM . C-7 JI ❑ I,as owner of the property,or my employees with wages as . r their sole compensation, will do the work and the structure ,530. ,.14.50 is not intended or offered for sale (Section 7044, Business Permit $ 1 IjEII.: and Professions Code). OWNER'S ❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE TOTAL 34 - 50 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAME NTRACTOR TO �"��// K Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. t.KIC34•:'C: CONSTRUCTION LENDING AGENCY k 11 , `. ,I I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19-u for the performance of the work for which this permit is OWNER oa T blwl issued (Sec. 3097, CIV. C.). OWNERS A ENADDRESS (`O_L001 ai 14; ( Lender's Name Lender's Address ��38 1 AM u 4v 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, a herebyf6i�horize representatives of this County to enter u thea ve mentioned property for inspection purposes. Si Lure f Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE 0-63 76A642D APPLICATION FOR PERMIT 6A642u COUNTY OF LOS ANGELES SEWER—SEWA . E DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS WILLIAM A. JENSEN, Sup't o4 Building L OCALiTY NEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL DESCRIPTION LOT NO. OWNER MAIL BLOCK TRACT ADDRESS NO. OF BLDGS. SIZE OF LOT NOW ON LOT CITY TEL NO. USE OF DISTRICT NO. GMAP PROCESS Y BUILDIROUP NGS K 0 /��(/) /f � ' -01 � �t CONTRALTO � -01V V /� ADDRESS I CONNECTION DATA C Y TEL. NO. /(s STATION S' � DEPTH 6-- ATEMANHOLE REFERENCE REGISTRATION NO. / ©/ v El COUNTY /,; ti ' LOWE NO. DESCRIPTION OF WORK FEE TYPE OF ON a• J LENGTH FROM HOUSE SEWER CONNECTING TO Y. CURB 1.L. M.L.TO P.L. PUBLIC SEWER @ E5.00 SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. JOB NO. V HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I W11IVII IASr MrNT RECORD,INSTR.NO. DATE WORK TO HOUSE SEWER @ $3.00 ovW OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN.,CESSPOOL,DRY WELL,MANHOLE @ $5.00 d ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING N SEWEP70R DISP SAL SYSTEM @ $3.00 STATE ENCROACHMENT Z PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES RAS P MIT s 2 00 AUT ORIZATI N TOTAL FEE /1i 7 CONNECTION CHARGE FEE 'I HAVE AT THIS DATE A CONTRACT WI HE HER IN NAMED CON. REIMBURSEMENT FEE TRACTOR TO CONNECT HE ABOVE DE C BED E TING DW ELLI G TO THE PUBLIC SE R APPROVALS DATE, INSPECTOR'S SIGNATURE SIGNED THIS DAY 111 OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC III TANK,SEEP,PIT(S)I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAI AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSED AS REQUIRED V LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT M THE L GAL OWNER OF, A INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABO DESCRI RES D NTIAnL P ERTY. ABANDON HOUSE SEWER SIGNATURE y BACKFILL SEPTIC TANKS ❑ OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑ VALIDATIO:�- '1 ROBERT( WOOD SUPERVISING MECHANICAL ENGINEER CK. M.O. CASH 1 6 6 0 J122 1 0 D 1 0.00 a 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 copy thereof(Sec. 3800, Lab C.) 92-0002 DPW 6/86 APPLICATION FOR PERMIT Policy No. Company El 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. v Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING I;-/ '% i; `^ \ STATION DEPTH COMPENSATION INSURANCE ADDRESS / J (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 ` �- I 1 LOWER NEAREST "(`� i �� TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. =+�' Y_ CURB P,I. M.L.TO P.L. permit is issued, I shall not emp any person in any manner `� P C.No so as to become subject to the o ers'Compensat oh Laws. OWNER �/. \ , 1'i _) jf S. CO.IMP.NO. JOB NO. _ MAIL � ( � `�'� TRUNK PERMIT NO. ROAD PERMIT NO. � Dote � `3Applicant � - ADDRESS � �� l.• - / NOTICE TO APPLICANT: If, after makingthis Certificate of r 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. S2 HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed I revoked. BLOCK TRACT yy STATE ENCROACHMENT NO.OF BLDGS. PERMIT NO. LICENSED CONTRACTORS DECLARATION �f 512E OF LOT / `� t � '.� 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 �%� '(.. '/Ll ' t .. CHARGES ness and Professions Code, and my license is in full force and effect. ` CONTRACTOR1,a CONNECTION CHARGE FEE License Number LIG Class �'� ADDRESS REIMBURSEMENT FEE J _ Contractor � \�D 3' Date t" ' j f°� r�+r�� DISTRICT NO. GROUP MAP PROCESSED BY } CITY i ( `` TEL.NO. "y�' / `✓�. b BK PG ❑ I am exempt under Sec. _of the L.A.Co. STATE No. .4• Y ciAss O DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the NO. FINAL � J HOUSE SEWER CONNECTING TO f '1 DATE VALIDATION B. & P. Code for the following reason PUBLIC SEWER 1 SEPTIC TANK,SEEPAGE PIT OR � L PITS AND/OR DRAINFIELD FINAL Date HOUSE VAT D WE CONNECT SY TEING TO BY PRISignature CONNECT ADDITIONAL BLDG.OR O CORNTO HOUSE SE OWNER-BUILDER DECLARATION OVERFLOW SEEPAGE PIT,DRAINFIELD , CL I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE LtJ Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE H fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,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). OWNERS Permit $ ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE r! licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED NTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY 1' .- I 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 OR issued (Sec. 3097, Civ. C.). OWNERS AGENT .7 ADDRESS Lender's Name Lender'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 hereby;authorize representatives of this County to enter U thea overmentioned property for inspection purposgs. Sig ature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE