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Home My Public Portal About6114 GOLDEN WEST AVE_Sewer__ WORKERS'COMPENSATION DECLARATION ' •4 1 hereb`sV ,affirm That I have a certificate of consent to self sure, orris c6rtificate of W rkers'Compensation Insurance, or 76A642D U ra certified copy thereof (Sec. 3800, Lab C.) CE 808IREV.1/83) 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 AL 6oS STATION DEPTH COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the �M MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY Te per t- G LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. 6AQ 73 A L,61 Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner ,r P.C.NO. so as to become subject to the Workkeers'1 Compensation Laws. OWNER MV 5 Lf, CO.IMP.NO. !OB NO. MAILa, V -W L—, �L,S5 L6 ADDRESS 5 TRUNK PERMIT NO. ROAD PERMIT NO. Date. Applicant_� ��j AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE O APPLICANT: If, after making this Certificate of CITY TEL,NO. 17205,-01 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 SIZE OF LOT ��i NNOO.OF N LOTS 2 PERMIT NO. W O 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 V CONNECTION CHARGE FEE License Number Lic.Class ADDRESS REIMBURSEMENT FEE Contractor .Dale - _/ �'y.� DISTRICT NO. GROUP MAP PROCES ED BY CITY TEL.NO. 60co w BK PG 0 ❑ I am exempt under Sec. of the L.A.Co. STATE CL (Ll P LICENSE NO. CLASS Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL -HOUSE SEWER CONNECTING TO DATE - VALIDATI B. & P. Code for the following reason PUBLIC SEWER 45 G SEPTIC TANK,SEEPAGE PIT OR FINA Date PITS AND/OR DRAINFIELD R/9 HOUSE SEWER CONNECTING TO 6Y 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 TN.,CESSPOOL,DRYWVERFLOW SEEPAGE PIT,DRAMANHOLE 5 0 9.2 A Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE # O 0,0 O 1 0 feS Ions Code): SEWER OR DISPOSAL SYSTEM I,as owner of the property,or my employees with wages as 1 21.50 their sole compensation, will do the work and the structure0 0 _ is not intended or offered for sale (Section 7044, Business dTR 2 1.5 0 v and Professions Code). OWNER'S Permit g ❑ I, as owner,of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 07,21 -86 ' licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO-Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SCONSTRUCTION LENDING AGENCYI hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 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 authorize representatives of this County to enter e 4 , upo ave-ment' n d property for inspecti n Zoses. ;>) -111�-yllt�� & ignature of P rmittee Dae SEE REVERSE FOR EXPLANATORY LANGUAGE 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 Policy Sop—thyeof,�S c, n800, Lam 6 / COESOB(REV.B/Bl) APPLICATION FOR PERMIT ❑ Certified copy is hereby furnished. �Gf 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 / O STATION j/ DEPTH COMPENSATION INSURANCE ADDRESS 1 `� O (This section need not be completed if the work involved by the MANHOLE REFERENCE �' UPPER LOCALITY �� G `^ permit is for one hundred dollars ($100)or less.) NEAREST TYPE OF CO TION LENGTH FROM f certify that in the performance of The work for which this CROSS ST. Y. CURM.L.TO P.L. 9- permit is issued, I shall not employ any person in any manner B P.L. > so as to become subject to the Workers' Compensation Laws. P.C.NO. OWNER CO.IMP.NO. - JOB NO. MAIL AD10TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant DRESS �^ +i-�. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE O NOTICE TO APPLICANT: If, after making this Certificate of CIT v r TEL NO. 10 Exemption, you should become subject to the Workers' W U LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY,OR ST,WIDENING 0. comply with such provisions or this permit shall be deemed a/! revoked.. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION No.OF BLDGS. PERMI NO. •�,/'" I hereby affirm that 1 am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE 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 CONNECTION CHARGE FEE License Number 1 ic.Class 72� ADDRESS ' < REIMBURSEMENT FEE Contractor 1 1194 jjfjt��A Date DISTRICT NO. GROUP MAP PROCESSED BY -� CITY �' TEL.NO. C— ry I am exempt under Sec. of the L.A.Co. STATE uC 4O BK PG P LICENSE NO. CLASS < Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL �- POUSE SEWER BLIC SEWER CONNECTING TO DATE 2 VALIDATION B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL Dote BY f -HOUSE SEWER CONNECTING TO �!' A""'°` -A-�-� -8 3 7,0 A PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ® c�o 0 0 1 0 OVERFLOW SEEPAGE PIT,DRAINFIELD �]' I hereby affirm That I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHO1E $ r� 0'0 2 / 5 0 Law for the following reason (Secton.7031.5, BUlsness.and Pro- ALTER,REPAIR OR ABANDON HOUSE L 1 fessions Code): SEWER OR DISPOSAL SYSTEM ❑ 1,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 sole (Section 7044, Business and Professions Code). OWNERS Permit O ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTALlicensed ContraCTOfS 10 construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH D CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DBLIC SEWER. CONSTRUCTION LENDING AGENCYI hereby affirm that there is a construction lending agency SIGNED THIS DAY OF19_ 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 hereMthOrinZ� esentatives of this County to enter upon thepropert for inspection purposes. �. Signal a of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE