Loading...
HomeMy Public PortalAbout5742 KAUFFMAN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I h6reby affirm that I have a certificate of consent to self 92-0002 DPW 3/87 insure, or ti certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT Policy Flo.�j2�2�y�,/�ompany s7'•e�L� �'Gf/`✓ �5 c PERMIT EJ Certified copy is ereby furnished. SEWER SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Datelc /► /���Applicant�: 5 l FOR APPLICANT TO FILL IN CONNECTION DATA IL C R FICATE OF COMPEN COMPENSATION INSURANCEPTION FROM ADDRESS ADDRESS 2/ �,� STATION � 115 DEPTH (This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE/ 3 UPPE ER permit is for one hundred dollars ($100)or less.) LENGTH FROM 4" NEAREST TYPE OF CONNECTION I certify that in the performance of the work for which this cRoss sT. irk dG 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 1�G1 P.C.NO. I P OWNER °CO.IMP,NO. JOB NO. MAIL TRUNK PERMIT NO, ROAD PERMIT NO. Date Applicant ADDRESS AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of ^'CITY TEL.No. h 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 " V, revoked. BLOCK TRACT STATE ENCROACHMENT , LICENSED CONTRACTORS DECLARATION v NO.OF BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT i I hereby affirm that I am licensed under provisions of Chapter US of I 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 �9� � CG�L/� (���C� CONNECTION CHARGE FEE License Numbec��03�� Lic.Class O � �• REIMBURSEMENT FEE 3 a ADDRES { DISTRICT NO. GROUP MAP •r;):,.`=:r;F PROCESSED BYRIi-J+� '.pi=y(�) Contracto r StyR�l�y�lDate u CIT 1i<_10' 1EL fjy�- STATE /+—� CLASS BK PG ��� O ❑ I am exempt under Sec. of th L.A.CO. LICENSE NO.y-� 3 v� CLASS NO. DESCRIPTION OF WORK FEE t` Plumbing Code and/or Sec. of the FINAL KALI ATI W i. HOUSE SEWER CONNECTING TO ��DATE PUBLIC SEWER 1 1 a B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY 12 PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER Poo. OVERFLOW SEEPAGE PIT,DRAINFIELD -?- µ'"-`'• I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE I+ _ i•T si~6 : '7r Law for the following reason (Becton 7031.5, BuiSneSS and Pro- ALTER,REPAIR OR ABANDON HOUSE ,e .t, ^ fig? €iJ fessions Cade): SEWER OR DISPOSAL SYSTEM ` ❑ I;as owner of the property,or my employees with wages as e #'€ =_ their sole compensation, will do the work and the structure ego is not intended or offered for sale (Section 7044, Business Permit $ and Professions Code). OWNER'S In ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE pp 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 I hereby affirm that there is a construction lending agency SIGNED THIS DAY OFG 19 for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, CIV. C.). OWNERS AGENT a- 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 '-- f'ri ordinances and State laws regulating Plumbing and Sewers, ` F-A and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. ignature of Per Date SEE REVERSE FOR EXPLANATORY LAggL1AtGE y WO2 RKERS'COMPENSATION DECLARATION 90002 DPW 3/87 1 hereby affirm that I have a certificate of consent to self 76A642D insure, or a certificate of Workers'Compensation Insurance, or CE 808, /� ® /� �p a certified copy th r f (Sec. ny Lab C.) APPLICATION OR PERMIT Policy N9'ao Company S�,a-�.� ��/ice ©s �❑ Certified copy s hereby furnished. SEWER - SEWAGE DISPOSAL k�l Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY depart a t. r Date Applicon—t;?"_ FOR APPLICANT TO FILL IN CONNECTION DATA CER IFICATE OF EXEMPTION FROM WORKERS` BUILDING ,d �� ( y LOCALITY STATION DEPTH COMPENSATION INSURANCE ADDRESS y rnl J�a/l/ This section need not be completed if the work involved b the MANHOLE REFERENC ✓J 2/�?3 �// PE ER permit is for one hundred dollars ($100)or less.) I certify that in the NEAREST /' TYPE OF CONNECTION LENGTH FROM y 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 P.C.NO. so as to become subject to the Workers'Compensation Laws. OWNER Q CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS AFFIDAVIT I WAIVER EASEMENT I RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY 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 NO.OLDGS. PERMIT NO. F B LICENSED CONTRACTORS DECLARATION s1zE OF Lor Now F B 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 / /^,, f�/yC'/� l�rC CONNECTION CHARGE FEE / License Numbe�"��,?1 3 LIC.Class ADDRESS /O C T REIMBURSEMENT FEE O COntracto 2V-_l - 1//yDate CIT f Iyt. y i- DISTRICT NO. GROUP MAP PROCESSED BY (� .� TEL. x �j BK PG ❑ I am exempt under Sec. of the L.A.Co. . � �3�'�STATE LIC. AO LICENSE NOSS U Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE I ! FINAL VALIDATION W HOUSE SEWER CONNECTING TO ' DATE (`o—jO`A PUBLIC SEWER ` `J "19 W B. & P. Code for the following reason N SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL 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 ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure •M1.? = a.T is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit $ ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE ,_ ^ "_35 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, s�''••I''+-i''' ""'= CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF T• 19 ® ::rid .,a_ o_ for the performance of the work for which this permit is OWNER OR �---s y issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS "'?1�^� •Lender's Name - =_rJUI�s 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 regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. Signature of P itt Date SEE REVERSE FOR EXPLANATORY LANGUAGE