Loading...
HomeMy Public PortalAbout6241 GOLDEN WEST AVE_Sewer__ 9 , • �`— WORKERS'COMPENSATION DECLARATION Il hereby affirm that I have a certificate of consent to self �I insure, or a certificate of Workers'Compensation Insurance, or 76A642D U Pzrfyfiid, B ere p 3800 Lob C.) CE 808(REV.1/83) APPLICATION FOR PERMIT ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY de artmt. / DatFOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FRO WORKERS' BUIL ING ADDRESS � / T DEPTH COMPENSATION INSURANCE (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 (,r 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 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.N 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.ORST.WIDENING O Q comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT < /�JA 0 LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. �J , r2 SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter u5E OF w �� 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDIN CHARGES ness and Professions Code;and my license is in full force and effect. �j`yam CONTRAC CONNECTION CHARGE FEE Lice s utF1b@r4 Lic.Class Y ADDRES URSEMENT FEE �, fe w J �T L r DISTRICT NO. GROUP MAP PROC S BY JC.d4'RrOd{(?/Q' - (6s:.— f CIT• aV ICJ �) BK PG 6pf UI's— El I am exempt under Sec. of the L.A.Co. i1cENSE No. CLASS �' �If �� @g Plumbing Code and/or Sec. of the NO. DESCRIPTION O WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE - / VALIDATION U B. & P. Code for the following reason PUBLIC SEWER Gam SEPTIC TANK,SEEPAGE PIT OR OL Date PITS AND/OR DRAINFIELD BV 4n HOUSE SEWER CONNECTING TO 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 4 1 7 0 A Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDO # HOUSE - .M o;O 0.0 54 fessions Code): SEWER OR DSPOSA Vyxw El 1,as owner of the property,or my employees with wages as i.a 1 91'282i their sole compensation, will do the work and the structure 0306-86 is not intended or offered for sale (Section 7044, Business and Profess ians'Code). OWNERS Permit $ ❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE S 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 OWNERS AGENT issued (Sec. 3097, Civ. C.). 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 upon the above-mentioned property for inspec ion purposes. ti ) Signature o ermiftee Date SEE REVERSE FOR EXPLANATORY LANGUAGE RKERS' COMPENSATION DECLARATION I heraby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Co ensation Insurance, or 76A642D certif e f (S C.) CE808(RE V.1/83) APPLICATION FOR PERMIT El Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY dear_tmZt.� � Date =e%icant 1,10. ► �,9 FOR APPLI ANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM W6 RKERS' BUILDING ATION ©.� DEPTH COMPENSATION INSURANCE ADDRESS (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 I certifythat in the performance Of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM p CROSS ST. Y. CURB P.I. M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws. P.C.NO. I P OWNE ` CO.IMP.NO. JOB NO. L T PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRE NOTICE TO APPLICANT: If, after making this Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE Exemption, you should become subject to the Workers' LEGAL Y 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 I am licensed under provisions of Chapter t pC USE OF 9 (commencing with Section 7000) of Division 3 of the BUST- BUILDINGS, PW CHARGES ness and Professions Code, and my license is in full force and effect. / CONTR CONNECTION CHARGE FEE Uf' -y/ Liceny1me Lic.Class • ADDR REIMBURSEMENT FEE �y a / DISTRICT NO. GROUP MAP PR ESSED BY 0 CITY -TEL. . j �22 0 J' PG STAT EJ1 am exe pt under Sec. of the L.A.Co. LICE k3 Plumbing Code and%•or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL g� J HOUSE SEWER CONNECTING TODATE PUBLIC SEWER 1 -7 -� VALIDA ION BM B. & P. Code for the'following reason y SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL r Date HOUSE SEWER CONNECTING TO BY 0 PRIVATE DISPOSAL SYSTEM Signature CONNECT O K TO HOUSE SEWER BLDG.OR OWNER-BUILDER DECLARATION OVERFLOW SEEPAGE PIT,DRAINFIELD 1 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 i fessions Code): SEWER OR DISPOSAL SYSTEM ❑ 1,as owner of the property,or my employees with wages as 4 1 7, 1 A their sole compensation, will do the work and the structure is not intended or offered for sole (Section 7044, Business Permit g # 0 0 0 0 1 0 and Professions Code). OWNER'S ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION FTOTAL FEE I 0 o27.50 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 0 o o 2 7.5 0 5 CONSTRUCTION LENDING AGENCY , 0 31 0 6 x 8 6 1 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 OWNERS AGENT issued (Sec. 3097, Civ. C.). 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 ordinanc s and State laws regulating Plumbing and Sewers, and eby horize representatives of this Count *to enter up t ov mentioned propertysp on rposes. i Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE