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Home My Public Portal About4840 GLICKMAN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm thoi I have a certificate of consent to self ,ansur6 oi-a certificate of Workers"Compenso n Insurance, or 76A642D a certified copy thereof(Sec3800, at Q'� �d 92-oao2DPWs,66 APPLICATION FOR PERMIT Policy No. or-----n -Certified copy is hereby furnished. SEWER SEWAGE DISPOSAL ❑ Certified copy is filed with building in COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant -7�l �� FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION F OM WORKERS' BUILDING UPPER COMPENSATION I URANCE ADDRESS 1 STATION DEPTH (This section need not be completed if the work involved by the LOCALITY I MANHOLE REFERENCE OWER permit is for one hundred dollars ($100)or less.) NEAREST LENGTH FROM / TYPE OF CONNECTION. % C/L 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 CO.IMP.NO. - JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS ' NOTICE. TO APPLICANT: If, after making this Certificate .of CITY TEL.NO. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE 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 1 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. J L. CONTRACTOR- ,G CONNECTION CHARGE FEE Licens Nu e. 1 Z! Lic.Class ` L ADDRESS �r L S REIMBURSEMENT FEE 8 Con OC CITY _ fera ,�j DISTRICT NO. GROUP MAP PROCESSED BY BK PG 0 El lam I am a STATE LIC. ----yempt under Sec. of the L.A.Co. LICENSE No. CLASS () Plumbing Code and/or Sec. of the No. DESCRIPTION OF WORK FEE FINAL W a HOUSE SEWER CONNECTING TO DATE i/ y/ VALIDATION fn B. & P. Code for the following reason PUBLIC SEWER / z SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR. , OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License EO TNFLOWSSPOOL,DRYWELRL,4INFIELD MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE Kid 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 -•' r= is not intended or offered for sole (Section 7044, Business = 1 I ,J4 m-`�i and Professions Code). OWNER'S Permit $ /Q 1. T.IEMS ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE jJ licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO i+_l i AL �+4 '0 BUSIneSS and P►OfeSSlOnS Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CHECK CONSTRUCTION LENDING AGENCY ._, ECK I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ OWNER OR �.•r�l-NGE for the performance of the work for which this permit is OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS Lender's Name LI_i�,iLl-'�i�ice'•� _; I�/4' 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 hereb authorize representatives of this County to enter upoyrt a ab ve-mentioned opert for i spection purposes. Sign.16re of Permittee Dpfe SEE REVERSE FOR EXPLANATORY LANGUAGE - J WORKERS'•COMPJENSATI'ON DECLARATION 1`herebyeaffirm that' I have a certificate of consent to self insure, or a certificate of Workers"Compensation Insurance, or 76A642D a certified cgpy thereof(Sec. 3800, La h Ci 92-0002 DPW 6,66 APPLICATION FOR PERMIT Policy No. Company 1✓1'0,l )iJG� Certified copy is hereby furnished. SEWER SEWAGE DISPOSAL 1:1Certified copy is filed with t my building in ection COUNTY OF LOS ANGELES BUILDING AND SAFETY department,. Date , Applicant r r Gl FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTIO FROM WORKERS' BUILDING COMPENSATION�NSURANCE ADDRESS v STATION DEPTH 3 (This section need not be completed if�the work involved by the f f MANHOLE REFERENCE UPPER LOWER permit is for one hundred dollars ($100)or less.) LOCALITY L- L I certify that in the performance Of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM permit Is.issued, I shall not employ an CROSS SL. Y. CURB P.L. M.L.TO P.L. p p y y person in any manner p,C'.NO. so as to become subject to the�Yor rs'Compensation LOWS. OWNER CO.IMP.NO. JOB NO. ( MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Appli an �— rLQ ADDRESS AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTIC TO. APPLICANT: If, after making this Certificate of J 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 NO.OF BLDGS. PERMIT NO. LICENSED CONTRACTORS DECLARATION slzl:oFLOT NOW ON LOT I hereby affirm that] am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busl- BUILDINGS CHARGES ness and Professions Code, and my license is.in full force and effect. �, CONNECTION CHARGE FEE '�7 c CONTRACTOR 34 Lice mber,� "� CONTRACTOR Class � � LL-g 1�.7 REIMBURSEMENT FEE ADDRESS /� CO tr to^. CITY O(.�� TEL. 1� 1�3g4 � [� DISTRICT NO. GROUP MAP PROCESSED BY 0 ❑ I a exempt under Sec. of the L.A.Co. STATE ��}} Llc. �o� �BK G,t LICENSE NO.�/0 g CLASS / Plumbing Code and/or Sec. NO. DESCRIPTION OF WORK FEE of the FINAL HOUSE SEWER CONNECTING TO DATEP� VALIDATION fA B. &P. Code for the following reason PUBLIC SEWER / _/o /[�—�` SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO - BY PRIVATE DISPOSAL SYSTEM Signature - CONNECT ADDITIONAL BLDG.OR , OWNER-BUILDER DECLARATION 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 Jr El 1,as owner of the property,or my employees with wages as ��` .7 their sole compensation, will do the work and the structure 607 `e _u is not intended or offered for sale (Section 7044, Business o�Y and Professions Code). OWNER'SPermit $ N t Isis•_• ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATIOTOTAL FEE licensed contractors to construct the ( ro•ect Section 7044, T}i 3`L _33 _50 P I , I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON ACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. �•�,-,'•Ld"F`:f 1 CONSTRUCTION LENDING AGENCY p'v_ I I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ , 4; FE'ut _ €1 for the performance of the work for which this permit is OWNER A OWNERS AGENT issued (Sec. 3097, Civ. C.). Lender's Name ADDRESS _ 111J8j1LL:i°�j 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 on a above-rnenti Pr Pe ,Y for inspection purposes. SigKature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION I hereby,,affirm that I,have' a certificate of consent to self c- insure, or a.certificate of Workers'Compensation Insurance, or 76A642D - a certified copy thereof(Sec. 3800, ----7> 92-0002 DPW 6/88 APPLICATION FOR PERMIT Policy No._ Comp )any S �-SZ Z J ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with a my building !qVection COUNTY OF LOS ANGELES BUILDING AND SAFETY de artm nt. Doli Applicant O FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTIpf FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS D C Vy�t q, (This section need not be completed if the work involved by theMANHOLE REFERENCE UPPER it permit is for one hundred dollars ($100)or less.) LOCALITY _ LOWER that in the performance of the Work for which 1hIS NEAREST 7 — TYPE OF CONNECTION LENGTH FROM I certify P CROSS ST.`d a– Z 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 CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS NOTICE TO APPLICANT: Ig CITY TEL.N0.f, after making this Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE 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 NOOF 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. CONTRACTOR G`Ka Tt 1_Q CONNECTION CHARGE FEE � Lice4 b@r✓!� 13G�t c ic.Class ADDRESS REIMBURSEMENT FEE DISTRICT NO. GROUP BK MAP PG O PROCESSED BY '0 CITY .NO. � El �� GQ TELI ar, e.empt under Sec.y of the L.A.Co. STATE NoF ALIC. ( CLASS14�:R , �U NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the FINAL CL HOUSE SEWER CONNECTING TO DATE L�,�`J �� VALIDATION !n B. & P. Code for the following reason PUBLIC SEWER o ,G z SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL ; Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE is Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 1�3 I� fessions Code): SEWER OR DISPOSAL SYSTEM _II ❑ 1,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure =i '� is not intended or offered for sale (Section 7044, Business -_ n and Professions Code). OWNERS Permit $ Q s if�•`_ El 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE j� _ET i34- 50 licensed Contractors 10 construct the project (Section 7044, I 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. C F=i.K 4°51i CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ , 'II-� li!�� °I_III for the performance of the work for which this permit is OWNER OWNERS A AGENT issued (Sec. 3097, Civ. C.). _ ii• ADDRESS !'?) ,i _li„[ 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 upo above-menti ropert for inspection purposes. Si ature of Permittee � Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION �J;Ihorebj_maffirm that h have a certificate of consent to self Insure, or a certificate of Workers'Compensation Insdrance, or 76A642D a certified mp copy thererof (See3800 ,— Q s2-oao2DPW 666 APPLICATION FOR PERMIT Policy No. Coan E�' e Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed witl�/Iina my building in on COUNTY OF LOS ANGELES BUILDING AND SAFETY depar ment' Dot Applicant 9 FOR APPLICANT TO FILL IN CONNECTION DATA CER IFICATE OF EXEMPTION OM WORKERS' BUILDING STATION DEPTH COMPENSATION I SURANCE ADDREss64 1 ma (This section need not be completed if the work involved b the j UPPER y LOCALITY C.' -[. MANHOLE REFERENCE - LOWER permit is for one hundred dollars ($1.00)or less.) I certify that in the performance of the work for Which this NEARE CROSS ST. t TYPE OF CONNECTION LENGTH FROM permit is issued, I,shall not employ an �� u Y. CURB P.L. M.L.TO P.L. p p y y person in any manner P.C.NO. so as to become subject to the Workers'Compensation Laws. OWNER CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS NOTICE, TO APPLICANT: If, after making this Certificate of CITY TEL.No. AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE 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. I hereby affirm that I am licensed under provisions of Chapter SIZE OFLOT NOW ON LOT 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. CONTRACTORS Q d - y 11 (� CONNECTION CHARGE FEE Licen��oGr/eAb` LIC.Class ADDRESS f I✓J REIMBURSEMENT FEE Cont/rptitbY DZteCITY qL� ' TEL.NO. DISTRICT NO. GROUP BK MAP PROCESSED BY PG �11 ❑ I am exempt under Sec. of the L.A. o. /0 i CENSE No.5-9q 9 t cLnss" �, -3 / Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK' FEE FINAL J C: j HOUSE SEWER CONNECTING TO /J� DATE �� / VALIDATION 0) B. & P. Code for the following reason / PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FINAL o PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR , OWNER-BUILDER DECLARATION 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 ❑ 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). OWNER'S Permit g _ QQ I aaC ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE J� licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON ACTOR TO TOT 41. AL 33 o _6E 6 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. d n•- CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ , laI clyll for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, CIV. C.). OWNERS AGENT ADDRESS Lender's Name i�$!sly—i_!{t�1 --7 lj',;'�i. Lender's Address -06 I certify that I hove 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 upo bove-Inentiop per y for inspection purposes. SigFt6ture of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE