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Home My Public Portal About4815 HALLOWELL AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or o.certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800, Lab C.) 92-0002 DPW 6/88 APPLICATION FOR PERMIT Policy No. Company ❑ Certified c.oPy is hereby furnished. SEWER SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date 1�^�"L— Applicant �'�•�" FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING y r STATION DEPTH COMPENSATION INSURANCE ADDRESS �+'Z O " f2. L L_ (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. 1-0 W A �V J 4� Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner subject to the Workers'Compensation Laws. P.C.NO. so as to become sub I P OWNER � � ,�'� CO.IMP.NO. JOB NO. MAIL •};. TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS 2 (� V-L� rb-- NOTICE TO APPLICANT: If, after makingthis Certificate of ay AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO. DATE an � a 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 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 USE OF R� 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS EJ CHARGES ness and Professions Code, and my license is in full force and effect. - CONTRACTOR ,"J, '`, C(y(� /,�..�,. 'CONNECTION C ARGE FEE T�1 License Number ��2 W2 7 Lic.Class C Q— ADDRESS le)14 % ��i�� s6I J REIMBURSEMENT FEE f v Contractor fL�:.'�'►'<<' .w Date "' -" 'Q a�°,� � � �+� DISTRICT NO. GROUPS MAP PROCESS/ED B1' 0 CITY ld3 0'R-� rE� TEL.NO.a -3 PG / �0TA ' ❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO. 02 1 LIC.ASS �- � Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL p J 0..' HOUSE SEWER CONNECTING TO DATE PUBLIC SEWER �-5// VALIDATION to B. 8 P. Code for the following reason p 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 il_} fessions Code): SEWER OR DIS AL SYSTEM _ ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure s' '54.fl is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit g ITENS ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE T I jTtj L 154 - 00 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. t. rlt 9- o as CONSTRUCTION LENDING AGENCY ./ Q 7 1 I hereby affirm that there is a construction lending agency SIGNED THIS j DAY OF +'�+� V 19 l0 ® CHANGe hl�f for the performance of the work for which this permit is OWNER OR Z-�.►, .,y�c2 issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS011-100-1,111,011 ..It ..s F,iCS Lender's Name ID 191 3:� Lender's Address :9-ZO 1 -HM 9:3.19 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 inspection purposes. ut Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate consent to self insure, or a certificate fosf Norkers'Comp n ion I once, or 76A642D Polcy'wNt �'Compan800" ` oe0e`REV.B e'' 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 dettfart nt. j Dater Applican✓/'/ G2� � FBUILDINGS FOR APPLICANT TO FILL IN CONNECTION DATA CER EXEMPTION FROM WORKERS' ING N DEPTH COMPENSATION INSURANCE ESS �� STATIO(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LITY � ` LOWER ST TYPE OF CONNECTION LENGTH FROM1 certify that in the performance of the work for which this S ST. Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any mannerso as to become subject to the Workers' Com ensation Laws. P.C.NO. I P R i � CO.IMP.NO. JOB NO. / oTRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ENOTICE TO APPLICANT: If, after making this Certificate of N a�� AFFIDAVIT WAIVER EASEMENT RECORD:INSTR.NO. DATE TEL.N p Exemption, you should become subject to the Workers' ALCompensation provisions of the Labor code, you must forthwith IPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.of LOT PERMIT No. F LOT NOW ON LOTI hereby affirm that I am licensed under provisions of Chapter F9 (commencing with Section 7000) of Division 3 of the Busi- INGS CHARGES ness and Profession Code, and my license is in-full force and effect. 2 CONTRA � Z, /t/ 5 CONNECTION CHARGE FEE License Nu ber LIC. CIgSS C J /� i// REIMBURSEMENT FEE Cant uaC /7'^�/��/�"- Date 4 / ADDRESS !/✓ - DISTRICT NO. GROUP MAP PROCESSED BY � CITY �� v/// G TEL.NO. �' STATE LIC BK PG g ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS �� 3 NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the FINAL. VALIDATION HOUSE SEWER CONNECTING TO DATE // B. 8 P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR FINAL g PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY 6l/ 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 ] Low for the following reason (Sectors 7031.S, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessioris Code.): SEWER OR DISPOSAL SYSTEM --+ ❑ I,as owner of the property, or my employees with wages as :m p their sole compensation, will do the work and the structure �' ' ''D is not intended or offered for sale (Section 7044, Business J _ and Professions Code). OWNER'S Permit $ /3 — i I^:t'= ❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE , -1 � L 34 . 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 Code). CONNECT THE ABOVE DE CRI EXISTING DWELL± TO THE PUBLIC SEWER. S•�S9-•_"• '° �';=' CONSTRUCTION LENDING AGENCY �.9 �d ��`(!j�EIt I hereby affirm that there is a construction lending agency SIGNED THIS D Y F 1 for the performance of the work for which this permit is OWNER A OWNERS AGENT issued (Sec. 3097, Civ. C.). r 1w1`-tMwrt s3 r ,f ADDRESS #,� 1 "S Lender's Name _ Lender's Address x� 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 u the a entioned property for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE