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HomeMy Public PortalAbout5734 KAUFFMAN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I'�e-epy affirm that I have a certificate of consent,to self '�•' ihSure,•dr'p certificate of Workers'Compensation Insurance, or 92-0002 DP W5/87 a certified co y thereof (Sec. ny Lab !; (CE APPLICATION FOR PERMIT- Pollcy,No. 1(�Q'+8960faompany 'CNA Ins•'CO• (CE 808) ❑ Certified copy-is hereby furnished: SEWER - SEWAGE DISPOSAL, <• �] Certified copy is filed with the"county building inspection COUNTY OF;LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIVISION department. Date 1-1-90: Applicant 'Oewn BIOS. Pl ing�ns. FOR APPLICANT TO FILL IN CONNECTION DATA . CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING " -•'COMPENSATION INSURANCE ADDRESS 5 7 34 Kauffman STATION DEPTH (This section need not be completed if the work Involved by the LOCALITY MANHOLE REFERENCE permit is for one hundred dollars ($100)or less.) LOWER I certify that In the performance of the'work for'which this NEARESTROSS TYPE OF CONNE ION LENGTH FROM permit Is issued, I shall not employ any person in any manner Y C B- P L M L TO P.L. so as to become subject to the Workers'Compensation Laws. PC No - OWNER Owen Develo men't 'CO.IMP NO 1 JOB NO. MAIL Applicant ADDRESS Date- 2035 S. Myrtle Ave. TRUNK PERMIT NO - ROAD PERMIT NO ' NOTICE. TO APPLICANT: If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE CITY Monrovia TEL No 818-359-32 1 1 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. .I'• BLOCK TRACT ' STATE ENCROACHMENT - LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NO I heSIZE OF LOT NOW ON LOTreby affirm that I am'llcensed under provisions of Chapter USE of ' 9 (commencing with Section 7000) of Division 3 of the Busl- BUILDINGS" CHARGES ne-ss and Professions Code; and my license is in full force and ` . effect. CONTRACTOR Owen Bros. Plumb in• Inc. CONNECTION CHARGE FEE s•+ ' License Number 231-741 Llc.Class C36-20 gppRES,SREIMBURSEMENT FEE. Contractor OWen BIOS. Plmb Date 9-30-89 CITY El Monte . TEL NO 818-443-0078 DISTRICT NO GROUP MAP ([� P SSEDBY STATE LIC. •� rBK / PG 0- ❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO 231-74.1 CLASS C36-20 , D 3 L U Plumbing Code and/or Sec. of the NO DESCRIPTION OF WORK FEE _ FINAL - HOUSE SEWER CONNECTING TO DATE VALIDATION' O B. 8 P. Code for the.following reason Q ` SEPTIC TANK,SEEPAGE PIT OR _ {yyam`` PITS AND/OR DRAINFIELD FINAL W' Date HOUSE SEWER CONNECTING TO BY ' PRIVATE DISPOSAL SYSTEM .. Signature CONNECT ADDITIONAL BLDG OR' ,;- ' OWNER-BUILDER DECLARATION WORK TO-HOUSE SEWER - 1-hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN,CESSPOOL DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR DON HOUSE' til fessions Code): - , . SEWER OR DISPOSAL SYSTEM ❑ I,as ownei-of the property,.or my employees with wages as their sole compensation, will do the work and the structure 27.50 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ i lTEI"- ❑ I,os owner of•the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE licensed contractors to construct thero"ect Section 7044, .� c7 °' _-E_� P I ( 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 27.5101 CONSTRUCTION LENDING AGENCY 4: _ SIGNED THIS DAY OF 19_ (':�,'= a t ji j I hereby affirm that,there is a construction lending agency }�,,.:,- _ for the performance of .the work for which this permit is OWNER OR' OWNERS AGENT = Issued (Sec. 3097, Civ. C:). ' Lender's Name ADDRESS i f�/ 4, 8�`f t' Lender's Address _ .'{ 3 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-lows regulating Plumbing and Sewers, and ereby authorize repre ntatives of this County to enter upo the ob ention r erty for inspection purposes. ' 3 ' �gnature of Permitte Date 'SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DKLARATIDN I herebv affirm that I have a certificate of consent to self '.nsurd; or a certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof Sec. 3800, Lab C CE 808(REV.8/81) APPLICATION FOR PERMIT Policy <0V ompanyi--62147 ©s ❑ Certified copy is hereby furnished. [�yt/, SEWER - SEWAGE DISPOSAL Certified co y is filed with the county building insp ctio COUNTY OF LOS ANGELES BUILDING AND SAFETY dep toren �s Dat Applicant ("—VIJ-2 -- RADDRE FOR APPLICANT O FILL IN CONNECTION DATA C TIFICATE OF EXEMPTION FROM WORKERS' / STATION DEPTH COMPENSATION INSURANCE L/, y(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) ^ LOWER I cerfif that in the erformance of the work for which this a T� TYPE OF CONNECTION LENGTH FROM Y P %'� " Y. CURB P.L. 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. E3 e `�1, CO.IMP.NO. !OB NO. +� '9 + TRUNK PERMIT NO. ROAD PERMIT NO. DateApplicant � AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of /✓�/ TEL.NO. ��7 -:-3 l� 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 0 Q STATE ENCROACHMENT LICENSED CONTRACTORS-DECLARATION NO.OF BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT p I hereby affirm that I am licensed under provisions of Chapter USE OF '(� .# 0 6 / 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS a CHARGES ness and Professions Code, and my license is in f}II for and effect. CONTRACTOR r��1� /'Lj j CONNECTION CHARGE FEE 1 � � License Number _Lic.Class f ADDRESS REIMBURSEMENT FEE DISTRICT NO. GROUP MAP PROCESSED BY U Contractor !1 �,�"� Date /-I— CITY �GTEL.NO. _ BK PG ❑ STATE LIC. I am exempt under Sec. of the L.A.Co. LICENSE No. �� cLAss � ( � NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the FINAL VALID ION ' HOUSE SEWER CONNECTING TO DATE B. & P. Code for the following reason PUBLIC SEWER ✓ 'j 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 I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,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 ❑ I,as owner of the property, or my employees with wages as LC- S their sole compensation, will do the work and the structure R L �� q 54 is not intended or offered for sale (Section 7044, Business a and Professions Code). OWNER'S Permit $ f F••:t_a =a ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE ".`•-Ii s�-1` a' i licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO t r r. Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. F I.�EMS CONSTRUCTION LENDING AGENCY $?G4 �O(J SIGNED THIS DAY OF 19_ TOTAL I hereby affirm that there is a construction lending agency T for the performance of the work for which this permit is A OWNER _34 CHECK issued (Sec. 3097, Civ. C.) OWNERS AGENT Lender's Name ADDRESS �; (j +jam _�I�I Lender's Ad re, s I certify t til hav ead this application and state that the 0010111-000 00 1, s`t ' above inf r atio Is torr ct. agree to comply with all County .-1, : : 1 _ f(� (;e0 ordinanc s and tate I ws efgulating Plumbing and Sewers, I-{ =` '�' and he y a thorize rep sentativeS of this County to enter Upo i abov -me Ion roperty for inspection purposes. \•' Sfignature c, ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE