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Home My Public Portal About9026 HERMOSA DR_Sewer__ WORKERS' COMPENSATION DECLARATION - 200051 DPW 6189 1 thereby d4C rm That have e certificate of consent to self )' insure, or d EertiticOte of Workers'Compensation Insurance, or 76A642D ° certified copy therea"Ser. 3800, `ab C., :_APPLICATION FOR PERMIT D Cy Na. company SEWER -SEWAGE DISPOSAL ❑ Certified copy is hereby furnished. t ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDIN,Zi.AND SAFETY department. '4 q_ Date Applicant _ FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGOG % STAnoN DEPTH COMPENSATION INSURANCE ADDRESS L-V (This section need not be completed if the work involved by the LOCALITY r 1 MaNHOIE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) - LOWER•' UNI FROM NEAREST t TYPE Of CONNECTION I'.certify that in the performance al nth work for which this caoss ST, D v Cuae PL ML TORE permit is issued, I shall nal employ any erson mliny manner LEGAL P{ NO SO °5 t0 become subject t0 ih2 ,A m n, tion Lows. DESCRIPTION LOT NO, CO IMP NO JOB NO BLOCK TRACT- TRUNK PERMIT NO ROAD PERMIT NO Dar an ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE NOTICE TOAPPLICANT: If, after making this Certificate of MAPBOOK PAGE PARCEL Exemption, you should become subject to the Workers' NO,OF BLUGS. Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked. ' BUILDINGS STATE.ENCROACHMENT - LICENSED CONTRACTORS DECLARATION �� yj� PERMIT NO � I hereby affirm that I am licensed under provisions of Chapter OWNER /J6 9 (commencing with Section 7000) of Division 3 of the Bust- MAIL , ADOREss CHARGES ness and Professions Code, and my license is in full force and effect. CITY TEL NO, CONNECTION CHARGE FEE License Nummbbberr��,( Ic.Ca55 ia4 MF N T.. REIMBURSEMENT FEE L.J'�Kl �Date // � / L CONTRACTOR DISTRICT NO GROUP MAP PROCESSED BY Contracto `�� A� _• Q ADORE `` �, p I C +� .ry ,( f� BX /PG yp�� ❑ I am exempt under Sec. of the L.A.Co. CITv rn Qlry/x /' �6<3 O gg J Cal' �- !o� Lys�G 0. TEL.NO u«L o. Plumbing Code and/or c. of the STATE .Z DC. eNAt p LICENSE No. GLASS I DnrE �_J2 �3 VALIDATION Z B. & P. Code for the 4 rea n NO. I DESCRIPTION OF WORK FEE O HOUSE SEWER CONNECTING 10 FINAL Date PUBLIC SEWER BY Q oHPTIC TANK SEEPAGE PIT OR W SignONre EAND OR DRAINFIELD W HOUSE SEWER CONNECTING 10 OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM , Z hereby affirm that I re exempt from the Contractor's license CONNECT ADUSE SEW BLDG OR Law for the following reason (Secton 7031.5, Buisness and Pro- wase TO HOUSE sl:wER fessions Code): OVERFLOW SEEPAGE PIT DRAINFIELD f XTN.CESSPOOL DRYWEIL.MANHOLE J,. f- ❑ I, as owner of the property, Or my employees with Wages as ALTER.REPAIR OR ABANDON HOUSE _ SEWER OR DISPOSAL SYSTEM - EM their sole compensation, will do the work and the structure _ - 7711 IC{3 £ -- is not m ended'or offered for sole (Section 7044, Business - - -. - t' r' and Professions Code). - - _ 1G(I 66 1111 ❑ I, as owner of the property, am exclusively contracting with Permit �T x til.:T .• licensed Contractors to construct the project (Section 7044, - OWNER'S Business and Professions Code). AUTHORIZATIONTOTAL FEE LAHANGE CONSTRUCTION LENDING AGENCY 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO I hereby affirm that there is O construction lending agency CONNECT WE ABOVE DESCRIBED Eiis NaG DWFIUNG TO THE PUBIC SEWER for the performance of the work for which this permit is Lila={'f-[I[hfi 7,i'.z/%`�:. issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OE 19— T1 x'-25 OWNER OR Lender's Name OWNERS AGENT Lender's Address 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 and Stole laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes, Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION 2oDD5t DPW 6x09 I hereby affVm that I have a certificate of consent to self msgce, or;o certificate of Workers' Compensation Insurance. or 76A642D ` a certified copy thereof (Sec. 3800. `ab C. APPLICATION FOR PERMIT Policy Na. Company rtlfled copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with the coup y ection COUNTY OF LOS ANGELES BUILDING AND SAFETY depart Ent. �� ' Date rfpplicont FOR APPLICANT TO FILL IN 'yS, CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS" BwLDING - 1 / COMPENSATION INSURANCE ADDRESS O snuoN �3 7 tD�i LQ DEPTH (This section need nor be completed if the work involved by the �� MANHOLE REF RENCE x �7 UPPER permit is for one hundred donors ($100) or less.) LOCALITY �_ F /Nf f / D LOWER //�� /] �/ certify that NEAREST TYPE OFrCCNNECTION LENGTH FROM the performance of the work for which this CROSSST. 1111 6 P �,IA r CURB Pt It 101i permit is issued, 1 shall not employ any person in any manner LEGAL so as to become subject to the Workers" Compensation Lows. DESCRIPTION LOT NO. P C NO CO IMP NO TOB NO Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT: If, after makingthis Certificate of A$BESSOR �j /� AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE MAP ROOK a PAGE PARL /� Exemption, you should become subject to the Workers' No.of eLOGS. Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR SI WIDENING comply with such provisions or this permit shall be deemed USE OF revoked. - BUILDINGS STATE ENCROACHMENT - - LICENSED CONTRACTORS DECLARATION ��Q�/q� PERMIT No I hereby affirm that I am licensed under provisions of Chapter OWNER �-0�. 1%G�u�+� 9 (commencing withSection 70001 of Division 3 of the Busi_ MAIL ness and Professions Code, and my license is in full force and ADDRESS ��//OZZ.� CHARGES effect. CITY TEL.NO.0// ( , Gi CONNECTION CHARGE FEE _ License Number "� Lic Class— /, ` REIMBUPSEMENT FEE Contractor /,I� //Dote —/ fs' CONTRACTOR /// DISI4ICl NO GROUP MAP PROCESSED BY ADDRESS ✓� /_� B. PG ' ❑ am exempt under Sec. of the L.A.Co. CITY TEL,NOc�Vjr ..f. Q Plumbing Code and/or Sec. of the STATE LIC, FINAL U LICENSE NO, CLASS DATE ^� VALIDATION zo B. $ P. Code for the following reason NO. DESCRIPTION OF WORK FEE J! HOUSESEWFR CONNECIING TO FINAL f Date PUBLIC SEWER Br U 5EPTIC TANK SEEPAGE PIT OR 10 W a Signature Pns AND OR oPAINHELD W HOUSE SEWER CONNECTING TO ACCT.. OWNERBUILDERDECLARATION PRIVATE DISPOSAL SYSTEM a 2 hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL RL Law for the following reason (Secton 7031 5, Buisness and Pro WORK tO HOUSE SEwE (.�. 3303 57.20 fessions Code): OVERFLOW SEEPAGE PIT RAINFIS D 1 ITEMSEXIN.CESS POOL.DY I MANHOLE ❑ I, as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE •� �-TI their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM TOTAL -CR/' - 2q,_p is not intended or offered for sole (Section 7044, Business and PrafFssions Code). q CLHEwE`CI•LK 57.in7 ❑ 1, as owner of the property, am exclusively contracting with OWNER'S Permit $ OS CTlttl`IVE .OV licensed contractors ra construct the project (Section 7044, Business and Professions Code). AUTHORIZATION I TOTAL FEE '• CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONI ACTOP TO oOfTf1�17001 i 1/17 fps I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER VL! 0 1 11 7 for the performance of the work for which this permit Is 333 1 AMli ?1 issued (Sec 3097, Civ. C.). SIGNEDDAv of w _ OWNER ORA Lender's Name OWNERS AGENT Lender's Address ADDRESS I certify that I have read this application and store that the ' above Iniormat ion is correct. I agree ro cc ply With all County ordino es a State lows regulating mbing and Sewers, and h reby a Far,ze repro SF mot.vEs this County to enter Upon t e o - property inspection purposes, Signature o Permittee Date SEF REVERSE FOR EXPLANATORY LANGUAGE