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Home My Public Portal About5833 GOLDEN WEST AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I herabu, affirm-1hat I have 'a certificate of consent to-self Insure; ar a'certificatb of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec 3800, Lab C ) CE808(REV 1,831 . APPLICATION- FORPERMIT Policy No Company ❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the co ildi ins n COUNTY OF LOS ANGELES BUILDING AND SAFETY department Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WOR RS' BUILDING 1p I �±�^�� COMPENSATION INSURANCE ADDRESS o �J /+12 6W �+J STATION DEPTH (This section need not be completed If the work involved by the LOCALITY L F_ MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less ) - LOWER NEAREST TYPE OF CONNECTION LENGTH FROM , I certify that, in the performance of the work for which this CRosS ST GJ v CURB P L M L TO P'L permit is issued, I shall not employ any person In any manner so as to become subject to the Work C!ompe ah La OWNER CO IMP NO JOB NO Date/—��// ��11 ., MAIL //tt J�� TRUNK PERMIT NO ROAD PERMIT NO Applicant �' — ADDRESS Hca I AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE NOTICE TO APPLICANT If, after making t Is ertif to of CITY j- Exemption, you should become subject 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 revokedBLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATIONNO OF BLDGS PERMIT NO SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencirig 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 do J¢ CONNECTION CHARGE FEE License Number LIC ClassADDRESS (/�.. REIMBURSEMENT FEE Contractor Dote �\ �� EL O DISTRICT NO GROUP MAP PROLE ED BY V CITY I� El am exerri t under Sec of the L A Co STATE LIC o{/ K PG P LICENSE NO � CLASS D O o-- Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE 2 VALIDATION W B & P Code for the following reason PUBLIC SEWER H SEPTIC TANK,SEEPAGE PIT OR FINAL Date PITS AND/OR DRAINFIELD FI z HOUSE SEWER CONNECTING TO • PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER 76 A OVERFLOW SEEPAGE PIT,DRAINFIELD O I hereby affirm that I am exempt from the Contractor's License EXTN,CESSPOOL,DRYWELL MANHOLE # 0.0 O O Low for the following reason (Secton 7031 5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code) SEWER OR DISPOSAL SYSTEM iI -'o 21.50 ❑ 1,as owner of the property,or my employees with wages as o o 0 2 �,5 Q= their sole compensation, will do the work and the structure C5 is not intended or offered for sale (Section 7044, BusinessI and Professions Code) OWNER'S - Permit $ 0 4-,-8 5 El'-I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE S6} 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 OF 19_ for the performance of the work for which this permit IS OWNER OR Issued (Sec 3097, Civ C ) OWNERS AGENT 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 thonze rep sentative of this ounty to enter upon the o e; enti d r rt f r ins tion purpose�� J w Signature of Permitt Date SEE REVERSE FOR EXPLANATORY LANGUAGE •,��j ORKERS'COMPENSATION DECLARATION I Hereby aIrm that I have a certificate of consent to self }1 Insure, or a certificate of Workers'Compensation Insurance, or 76A642D U a certified copy thereof (Sec 3800, Lab C , CE 808(REV 1/83) APPLICATION FOR PERMIT Policy No Company , SEWER - SEWAGE .DISPOSAL ElCertified copy Is hereby furnished E:1 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 TTi� r�' STATION DEPTH COMPENSATION INSURANCE ADDREss933 Ly�•Y �_r (This section need not be completed if the work Involved by the LOCALITY �� Ty MANHOLE REFERENCE LOWER permit Is for one hundred dollars ($100)or less ) OM I certify that in the performance of the work for which this CROSS NEARESST qq r` TYPE OF CONNECTION M L TOP L a.� Y CURB P L M l TOP L permit is Issued, I shall not employ any person in any manner PC NO so as to become subject to the Work�lelr Comp atlon L ws OWNER QaC CO IMP NO JOB NO MAIL%j pJ f�- � ADDRESS 3. �S TRUNK PERMIT NO ROAD PERMIT NO Date Applicant �•' NOTICE TO APPLICANT If, after making t Certi ate Of CITY J 4- y O ^4 y AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE Exemption, you should become subject o the Workers' LEGAL C/ 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 PERMIT NO SIZE OF LOT NOW ON LOT LOT � I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commenting with Section 7000) of Division 3 of the Busi- BUILDINGS - CHARGES ness and Professions Code, and my license Is in full force and �J effect CONTRACTOR .� �/� l., m 6(/l( CONNECTION CHARGE FEE License Number LIC Class ADDRESS //�^ L REIMBURSEMENT FEE Contractor . Date CITY �1 / EL NO ��457 DISTRICT NO GROUP MAP PROCESSED BY 0 STATE / LIC ,,��'' BK PG V ❑ 1 am exempt under Sec of the L A Co LICENSE NO / CLASS V` `1 GC Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL O HOUSE SEWER CONNECTING TO DATE VALID ION B 8 P Code for the following reason PUBLIC SEWER V SEPTIC TANK,SEEPAGE PIT ORd PITS AND/OR DRAINFIELD FINAL N Date BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAIN FIELD 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 ;23525A their sole compensation, will do the work and the structure Is not.intended or offered for sole (Section 7044, Business # 0 0 0 0,1 0 and Professions Code) OWNER'S Permit ; O 'i ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE I A I 1 5- J o o 2 1.5 0 licensed contractors 10 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 o ® o 2 1.5 0 U CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF i1.2.1'—8 5 for the performance of the work for which this permit Is OWNER OR OERS AG issued (Sec 3097, Civ C ) WNENT ADDRESS Lender's Name Lender's Address I certify that I hove read this application and state that the above Information is correct I agree to comply with all County ordinances End State laws regulating Plumbing and Sewers, and hereby 5pti5grize representative of this C unty to enter upon the a ve ee bone roperty_ r rispe on p s s� LJ � Signature of Permitt a Date SEE REVERSE FOR EXPLANATORY LANGUAGE