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Home My Public Portal About5723 GOLDEN WEST AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 1 hereby affirm that I hove a certificate of consent to self 200051 DPW 6189 ,+sure, or o certificate of Workers' Compensation Insurance, or 76A642D a certified copy thereof (Sec 3800,- APPLICATION FOR PERMIT Policy No Company ElCertifiedcopy Is hereby furnished �Pt F0 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 �+ COMPENSATION INSURANCE ADDRESS � We STATION � f a�/, � DEPTH (This section need not be completed If the work Involved by the ^ MANHOLE REFERENCE t(� UPPER permit is for one hundred dollars ($100) or less ) LOCALITY `.w LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this'. CROSS ST b n' i(;�, Y CURB P L M L TO P L permit is issued, I shall not employ any person In any manner LEGAL PC NO so tas to become subject to the Wor ers' Compensation Laws DESCRIPTION LOT NO CO IMP NO JOB NO ��' Z - BLOCK' TRACT TRUNK PERMIT NOT ROAD PERMIT NO 'Dae Applicant �; - ASSESSOR , �{ / AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE _ NOTICE TO APPLICANT If, afte making this Certificate O MAP BOOK / PAGE a513PARCEL 9!9b f� 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 HWY OR ST WIDFNING comply with such provisions or this permit.sholl be deemed USE OF revoked BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION 14 eso%ij PERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER �0 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL CHARGES ness and Professions Code, and my license is in full force and ADDRESS effect /�_�/� CITY TEL NO CONNECTION CHARGE FEE Licens mber� Class .4 1 �Q REIMBURSEMENT FEE J a� CONTRACTOR Reze 14<7 COMraC A .[^i DISTRICT NO GROUP MAP PROCESSED BY ADDRESSiZ* Sw I Y• r BKPG F-1I am exempt under Sec of the L A Co CITY ATE +� / Q O Qf f-9 C / Plumbing Code and/or Sec of the STATE" �] LIC FINAL O LICENSE NO —1Z ff CLASS DATE VALIDATION V B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE )✓�� Z O HOUSE SEWER CONNECTING TO FINAL 1'- Date PUBLIC SEWER (/ BY V SEPTIC TANK SEEPAGE PIT OR W Signature PITS AND OR DRAINFIELD 0. HOUSE SEWER CONNECTING TO 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 _! OVERFLOW SEEPAGE PIT DRAINFIELD fessions Code) EXTN CESSPOOL DRYWELL MANHOLE i ALTER REPAIR OR ABANDON HOUSE ❑ 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 structureii 1 Is not Intended or offered for sale (Section 7044, Business and Professions Code) �-F ❑ I, as owner of the property, am exclusively contracting with OWNER'S Perm 11 $ /' Tib I i�iL 3L 10 licensed contractors to construct the project (Section 7044, Business and Professions Code) AUTHORIZATION TOTAL FEE t.':f CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A'CONTRACT WITH THE HEREIN NAMED ONTRACTOR TO I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER .i� L7� for the performance of-the work for which this permit is issued (Sec 3097, Civ C ) SIGNED THIS DAY OF 19OWNER _ OR 4 Lender's Name OWNERS AGENT f }I_i ,Li; a-. -- 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 jaws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upo above-mentioned ropers Lfor inspection purposes Sign ure of Permittee yto Date r:� SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION 20-0051 DPW 6189 I hereby 6fflrm-that I hove a certificate of consent to self - Insure O,r a crerf�4cafe of Workers' Compensation Insurance, or 76A642D a certified copy thereof (Sec 3. lab C ) APPLICATION FOR PERMIT Policy No • 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 STATION DEPTH COMPENSATION INSURANCE ADDRESS 72Al. f�If'/' (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 -/ 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, I shall not employ any person In any manner LEGAL P C NO so as f0 become subject to the Workers' Co pe nsation Lows DESCRIPTION LOT NO 62 CO IMP NO JOB NO uvzl BLOCK TRACT 65-61 TRUNK PERMIT NO ROAD PERMIT NO Date Appl cont.I NOTICE TO APPLICANT If, after makin this Certificate Of ASSESSOR �� AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE MAP BOOK 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 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 Busl- MAIL /�/ CHARGES ness and Professions Code, and my V license is In full force and ADDRESS effectCITY CL TEL NO T6 CONNECTION CHARGE FEE License Number LIC Class REIMBURSEMENT FEE CONTRACTOR Contractor Date DISTRICT NO GROUP MAP PROCESSED BY ADDRESS BK PG ❑ I am exempt under Sec of the L A Co _3 } CITY TEL NO E 0 Plumbing Code and/or Sec of the STATE LIC FINAL U LICENSF,40 CLASS DATE '``/J/ VALIDATION Z B & P Code for the following reason NO DESCRIPTION OF WORK FEE lL "Cllr Q HOUSE SEWER CONNECTING TO FINAL - F— Dote PUBLIC SEWER BY `U SEPTIC TANK SEEPAGE PIT OR d Signature PITS AND OR DRAINFIELD OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING SYSTEM ro ► 10 2 PRIVATE DISPOSAL SYSTEM 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 HOUSE SEWER O INFIELD ACCTea g ) fes Ions Code OVERFLOW SEEPAGE PIT LL MANN EXTN CESSPOOL DRY WELL MANHOLE j57.201, as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE 3JW, �7s0 their sole compensation, well do the work and the structure SEWER OR DISPOSAL SYSTEM 1 ITEMS is not Intended or offered for sole (Section 7044, Business and Professions Code) TOTAL 57 - 20 ❑ 1, as owner of the property, am exclusively contracting with OWNERS Permit $ CHECK 57.20 licensed contractors to construct the project (Section 7044, Business and Professions Code) AUTHORIZATION I TOTAL FEE CHANGE .00 CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ICONTRACTORI hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBfor the performance of the work for which this permit Isa0017_Q001 1/?3I96 Issued (Sec 3097, Civ C ) SIGNED THIS DAY OF V U OWNER A 4395 -1 PM 6:28 Lender's Name OWNERS AGENT Lender's Address ADDRESS 1 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 upon th above- e tioned prop6rty for Inspection purposes C� Y 6 - Signature a IQJ rmittee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE