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Home My Public Portal About6100 IVAR AVE_Sewer__ 'WORKERS'.COMPENSATION DECLARATION '',,hereby-pL,fi6 thgt I'have a certificate of consent to self in�ire,.or p certificate-of Workers'Compensation Insurance, or 76A642D �a certified copy thereof (Sec. 3800, Lab C.) CE808(REV.I/83) n��n ��/�`��®fin FOR (��nf�� Policy No. Company A cc L (�=, u`j Lr M ❑Certified copy is hereby furnished. SOWER e SEWAGE ®OSPOSAL ❑ 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' BUILDINGSTATION DEPTH COMPENSATION INSURANCE ADDRESS I� (This section need not be completed if the work involved by the LOCALITY LOWER MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)Or less.) NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which t 's cROSS ST. ( Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not empl y ny person i any man r P.C.NO. so as to become subject to the O ers'C mpe oti OWNER % CO.IMP.NO. !OB NO. MAIL `' TRUNK PERMIT NO. ROAD PERMIT NO' Date S Applicant ADDRESS O. �/# AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, r making this C I to of ^CITY TEL.NO. Q Exemption, you should become subject to the orkers' 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 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 Lic.Class ADDRESS - 'REIMBURSEMENT FEE AL DISTRICT NO. GROUP MAP PROCESSED BY O Contractor Date CITY TEL.NO. BK PG ❑ I am exempt under Sec. of the L.A.Co. LICENSE STATE LIC. CLASS 5i✓ �� ' C,4/' 10 Plumbing Code and/or Sec. of the NO. DESCRIPTIONOF WORK FEE 1?_FINAL VALIDA O� U HOUSE SEWER CONNECTING TO DATE B. & P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FI PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO B PRIVATE DISPOSAL SYSTEM Signature' - CONNECT ADDITIONAL BLDG.qR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWERO OVERFLOW SEEPAGE PIT,DRAINFIELD :2 2 / /� D. r7 5 3A- Ihereby 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. # O O O O 1 0 fessions Code): SEWER OR DISPOSAL SYSTEM �6dJ I.as owner of the property,or my employees with wages as f o,o 2 1.50 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business o 0 0 2 �,5 Q and Professions Code). OWNER'S" Permit $ - 05-o ❑ I,a's owner of the property, am exclusively contracting with AUTHORIZATION r TOTAL FEE S 0 a2 O'`8 5 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 Tr I hereby affirm that there is a construction lending agency SIGNED THIS YO 1 for the performance of the work for which this permit is OWNER OR OWNERS kGENIM issued (Sec. 3097, Civ. C.). /tel , 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 re sting Plumbing and Sewers, and hereby authorize re res rives of this County to enter p n theave- nt' ert for inspection purposes. S gnature of Permitt Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION CE 808 (D2-80) {S P P L_I C A T �O v FOR 1PERMIT � E R Y° B T I hel insu eeby affirm that I K 6d certificate of consent to self SEWER-SEWAGE ®I S Ir OSA L certificate o or ers'Compensation Insurance,or !.,�'r a at.r�e-rt�f yt' e (Sec. 3800,Labe.) � �y�i COUNTY OF LOS ANGELES BUILDING AND SAFETY lic o Company Certified copy is hereby furnished. FOR APPLICANT T LL IN CONNECTION DATA BUILDING �A NATION ��V � � DEPTH /, a Certified copy is filed with th cou/rn/tyfy�build/i�n�/gJin�s�p�e�ction/y� ADDRESS C/J` ._ NGS V Daepatyt� nt• /ppllCa �y :✓ / J LOCALITY r MANHOLE REFERENCE J ' LOWER NEAREST TYPE OF CTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss sr. ! Y. cuRB P.L. M.L. TO P.L. COMPENSATION INSURANCE { P,1, NO. OWNER .� �jy.�„�% CO. IMP. NO. 30 JOB NO. MAILa (This Section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO.5w/y�;;O Q by the permit is for one hundred dollars ($QQ100) Or less.) /� AFFIDAVIT ANER EASEMENT RECORD.INSTR,NO. DATE U CITY TEL. NO. _ � W I certify that in the performance of the work for which this LEGAL permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING 0 so as to become subject to the Workers' Compensation Laws. ` U BLOCK TRACT f STATE ENCROACHMENT W Date Applicant NO. OF BLDGS. PERMIT NO. d NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF LOT. NOW ON LOT / ` J�� z Exemption, you should become subject to the Workers' usE o %,i CHARGES Compensation provisions of the Labor Code, you must forth- Bu1LD' Gs �� _ !y1 �� if�-� with comply with such provisions or this permit shall be j CONNECTION CHARGE FEE deemed revoked. CONTRACTOR ,REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION AD Ess I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP MAP PROCESSED Y 9 (commencing with Section 7000) of Division 3 of the Busi- T� /1 zEL"—No• — � STAT ness and Professions Code, and my license is in full force and L Co ENSE rv . [/ ' cLAss effect. NO. DE CRI TION OF WORK FEE ✓I(7 HOUSE SEWER CONNECTING TO •' FINAL VALIDATION Lice0e Number i Lie.Class `� / I PUBLIC SEWER DATE j l{��f , )/ SEPTIC TANK,SEEPAGE PIT OROXY /- _(9//Date `L+��V PITS ANO(OR DRAINFIELD.kt FINAL, I. HOUSE SEWER CONNECTING TO BY ❑ PRIVATE DISPOSAL SYSTEM ' I am a empt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD iness and Professions Code). EXTN.,CESSPOOL,DRYWELL, MANHOLE ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lie.or Reg.No. Date HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNER'S Permit 8 D License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE z 0 9.-a.0 A ness and Professions Code): , HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- 0 #ID D D O 1 TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING 1, as owner of the property, will do the work and the TO THE PUB T R LIC SEWER 3 I I ❑ structure is not intended or offered for sale (Section SIGNED HIS DAV OF / 19 2 ° ° 8.0 0 7044, Business and Professions Code). OWNER o OWNERS AGENT D O O 1 8,0 0 CONSTRUCTION LENDING AGENCY ADDRESS I hereby affirm that there is a construction lending agency 0.�27—8 1 for the performance of the work for which this permit is issued (Sec. 3097,Civ.C.). Lender's Name a 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 ordi,ances and State laws regulating Plumbing and Sewers, a hereby authorize representatives of this County to enter on the above-mentioned property f Inspection pu oses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pe ittee D e