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HomeMy Public PortalAbout4931 HELEO AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm that 1-have a certificate of consent to self ,LA nsure, ar a certificate of Workers'Compensation Insurance, Or 76A642D P certified co thereof Sec. 3800, Lab C. CE 808(REV.8/81) D no n M FOR PUNT Policy No.—Company Company ) ©s '" "Ph'ppL�ppp rC� UOpppp" FOR l�L511�NT ❑ Certified copy is hereby furnished. e�JLS�7GER - SEWAGE CSE DIMPOSAL ❑ 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 dl (This section need not,be completed if the work involved by the LOCALITY • MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOWER NEAREST .y"'� TYPE OF CONNECTION LENGTH FROM I' certify that in the performance of the work for which thi cRoss ST.. y / �.3 Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person�innany mann r P.c.No: soas to'become'subject to the Workers'Compeon Law OWNER CO.IMP.NO. JOB NO. MAIL TRUNK PER NO. ROAD PERMIT NO. �Dat� �.� Applicant ADDRESS NOTICE TO APPLICANT: If, after 'makin this Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE g CITY TEL.NO. �� Exemption, you should become subject to the WorkersLEGAL 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 NO,OF BLDGS. PERMIT NO. LOT NOW ON LOT I hereby affirm that l 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.- {//�]� CONTRACTOqJ CONNECTION CHARGE FEE License Numbe ~ n 1C. Class— ADDRESS" �� 1• REIMBURSEMENT FEE O Contractor f OatesDISTRICT NO. GROUP MAP PROCESSED BY ' - CITY G ja/ANO. 0 k2BK PG O ❑ I am exempt under Sec. of the L.A.Co. ueENSE No. - / . {4 ciAss i < <O(J L Q� t' NO. .DESCRIPTION OF WO FEE W Plumbing Code and/Or Sec. Of the HOUSE SEWER CONNECTING TO DATEFINA ,/ VALIDATION B. & P. Code fo-r the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD e 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 fessions Code): SEWER OR DISPOSAL SYSTEM .: ACT ..JL .. 1,as owner of the property,or my employees with wages as X14 p their sole compensation, will do the work and the structure 3307 154.00 is not intended or offered for sale (Section 7044, Business - and Professions Code). OWNER'S Permit • g AUTHORIZATION T -❑ I,as owner of the property,am exclusively contracting with TOTAL FEE 2 EMO. licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON RACTOR TO.. i ITEMC b 6 Business and Professions Code). CONNECT THE ABOVE'DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.' TOTAL CONSTRUCTION LENDING AGENCYJ I hereby affirm that there is a construction lending agency SIGNED THIS DQAY F - 19_ CHECK _ for the performance of the work for which this permit .is OWNER o issued (Sec. 3097, CIV. C.). OWNERS ENTKA�vCHANGE .00 ADDRESS ........... Lender' me Le der's A dress 0000-0301 S/ 4/39 I certify t at I have read this application and state that the f.00— Ve�� bove irr rmation 1 Mc I agree to comply with all County ordin n s and State law regulating Plumbing and Sewers, and Eby authorize repre entati es of this County to enter U o above-mentioned p-per for inspection purposes. " gnatur of tee Date SEE REVERSE FOR EXPLANATORY LANGUAGE t: WORKERS'COMPENSATION DECLARATION Of—hereby affirm that I have a certificate of consent to self insure, oro certificate of Workers'Compensation Insurance, or 76A642D /_� f�'�f1 /� n M I'�} �� a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.B/81) Jo�PIPL, PCAV�Ou V FOR [PIER 'T Policy No. Company OO s APIPL, ppp PCAVOM Tipp ra� 2pp ❑ Certified copy'is hereby furnished. SEWER a SEWAGE DOS OSAL5 ❑ Certified copy is filed with the county.building inspection COUNTY OF LOS.ANGELES BUILDING AND SAFETY department Date Applicant FOR APPL CANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' A COMPENSATION INSURANCE ADDRESS STATION V DEPTH (This section need not be completed if the work involved by the J / MANHOLE REFERENCE J� UPPER permit is for one hundred dollars ($100)or less.) LOCAuiY S . U V LOWE NEAREST g TYPE OF CON ECTION LENGTH FROM I certify that in the performance of the work for which this 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 ers'Com ensatio Laws. P.C.No. _I p y1 OWNER CO.IMP.NO , JOB NO _ (l/Y [� / G. MAIL TRUNK PERMIT NO ROAD PERMIT NO. Dat `e�� / / Applicant V ADDRESS J. NOTICE TO APPLICANT: If, fter making this Certificate of CITY TELNO. 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.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. 1 hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW.ON LOTUSE OF 9 (commencing with Section 7000) of Division 3 of the BUST- BUILDINGS CHARGES ness and Professions Code, and my license is'in full force and effect. - 2CONTRACTOR �.—• CONNECTION CHARGE FEE License Numbe iC.Class _q ADDRESS ! REIMBURSEMENT FEE 0 Contracto /_1 41ate p'i f•�r CIT • ✓ NO � DISTRICT NO. GROUP 'MAP - PROCESSED BY u BK PG ` � �i �o� El am exempt under Sec. of the L.A.Co. STATE LIC. { P LICENSE NO. i L CLASS V NO. DESCRIPTION OF WOR F Plumbing Code and/Or Sec. Of the HOUSE SEWER CONNECTING 7 / DATE VALIDATION 911. B. 8 P. Code for the following reasonPUBLIC SEWER" H SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date BY 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 1 'Law for the following reason (Sectors 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ACCT A' ❑ I,as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure 3307 27.50 is not intended or offered for sale (Section 7044,Business and Professions Code). OWNER'S Permit $. �Q J. 1 ITEMS ❑ I,as owner of the property„am exclusively contracting with AUTHORIZATION FiOTAL FEE' J O TOTAL 27.150 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO CHECK Business and Professions Code). .CONNECT THE ABOVE DESCRIBED EXISTAIDWEL TO THE PUBLIC SEWER. CnGCP` 7oC;:CONSTRUCTION LENDING AGENCY �Ly,�p��^I hereby affirm that there is a construction lending agency SIGNED THIS DA % `? 1 O CHANGE. o00 for the performance of the work for which this permit Is OWNER OR issued (Sec Civ. C.). OWNERS AGE f it Lender' NamZ ADDRESS 0000-0001 8, it 8 Len is Adds 9 4870 1 PM12.10 I c rtify th I have read this application and state that the : a ve i mation is correct. I agree to comply with all County o dino c and State laws regulating PI tubing and Sewers; d h r y authorize sentat ives this County to enter above one roperty fo i ection purposes. �A `t of rmLee Date SEE REVERSE FOR EXPLANATORY LANGUAGE