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Home My Public Portal About6014 KAUFFMAN AVE_Sewer__ �°t a WORKERS' COMPENSATION DECLARATION 1.,hereby affirm that I have a certificate of consent to self 200051 DPW 6189 insure, or a certificate of Workers' Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800 Lab C. �� APPLICATI®N FOR PERMIT Policy No. Compony LICertifiedcopy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. 1 1� Datew Applicant!Mf ctjk5m FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS STATION _ DEPTH (This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100) or less.) LOCALITY _ OWER I certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION MLLENGTHFROM CROSS ST. V CURB PL M L TOO P L permit is issued, 1 shall not employ any person in any manner LEGAL PC NO so as to become subject to the Workers' Compensation Laws, DESCRIPTION LOT NO. CO IMP NO JOB NO BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO Date Applicant ASSESSOR / AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE NOTICE TO APPLICANT: If, after making this Certificate of MAP BOOK PAGE 27 PARCEL Exemption, you should become subject to the Workers' NO.OF BLDG . 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 PERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER Zz 115 P� 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL CHARGES ness and Professions Code, and my license is in full force and ADDRESS effect. CITY G TEL.NO. - O CONNECTION CHARGE FEE License Number Lic.Class C • ` l�l REIMBURSEMENT FEE WA1e 1� '//1� CONTRACTOR wok-n b•L DISTRICT NO GROUP MAP PROCESSED BY Contractor ( ADDRESS � ,f� BK PG ❑ I am exempt under Sec. of the L.A.Co. TEL.NO. �" D(! .5 (� �L } CITY I& a O Plumbing Code and/or Sec. of the STATE LIC. FINAL LICENSE NO. 2, $ CLASS Z. DATE Q_1 VALIDATION v B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE V ` o OUSE SEWER CONNECT FINAL F- Date I UC SEWER BY 0 SEPTIC TANK SEEPAGEW PTT OR d PITS AND OR DRAINFIELD Signature to OWNER- ILDER DECLARATION HOUSE DISPOSAL CONNECTING SYSTEM To Z PRIVATE DISPOSAL SYSTEM I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR , Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER feSslans Code): OVERFLOW SEEPAGE PIT, DRAINFIELD 230 11 154.CND ) EXTN,CESSPOOL DRV WELL,MANHOLE - ALTER, REPAI OR ABANDON HOUSE y � .�-'•e ElI, as owner of the property, or my employees with wages as SEWER ORD POSAL SYSTEM �'-•��—U their sole compensation, will do the work and the structure TOTAL -1 54 ® 00 is not intended or offered for sale (Section 7044, Business and Professions Code}. -" -i �.K; c 4.0, 1 ❑ I, as owner of the property, am exclusively contracting with OWNERS Permit $ s'' }6q licensed contractors to construct the project (Section 7044, vl�ttl'i1E .tit( Business and Professions Code). AUTHORIZATION TOTAL FEE --' CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ' CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER —!,.n,._ I hereby affirm that there Is a construction lending agency 3;I�Ei;�-00l�1 ,•p�L€.;'�_; for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_ jiL 5.+1 j I OWNER OR - Lender's Name OWNERS AGENT " Lender's Address 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 authorizer presentatives Of this County to enter upon the above-menti n +property for inspection purposes. }_ v19 71 - Signatur Kof Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION I hkereby affirm that I have a certificate of consent to self insure,,or to certificate of Workers'Compensation Insurance, or 76A642D a certified copxthereo , Se 38 Lgb-£. LL ;y� 92-0002 DPW 6/88 APPLICATION FOR PERMIT Policy No ElCertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certifie cop is filedwith the cou ing in COUNTY OF LOS ANGELES BUILDING AND SAFETY de art en Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA RTIFICATE OF EXEMPTI N FROM RKERS' BUILDING COMPENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed if the work involved by theLocALITv MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOWER NEARET I certify that in the performance of the work for Which this CROSSSST. ® TYPE OF CONNECTION LENGTH FROM Y. cuae PL. M.L.TO P. permit is issued, I shall not employ any person in any manner P. subject to the Workers'Compensation Laws. P.C.NO. so as to become sub I P OWNER /�-- • CO.IMP.NO, JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date < Applicant ADDRESS NOTlC AFFIDAVIT. WAIVER EASEMENT RECORD.INSTR.NO. DATE TO APPLICANT: If, after making this Certificate of CIT L.NO. �{J?j® =Exemption, you should become subject to the Workers' LEGAL pensation 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 DENOOF BLDGS. PERMIT NO. CLARATION 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�5a . Cla ~� ADDRESS REIMBURSEMENT FEE COntfaClD/ Date �/ ID DISTRICT NO. GROUP MAP PROCESSED BY CITY TEL.NO. L% BK PG (� ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASr Plumbing Code and/or Sec. of the NO. DESCRIPTION O WORK FEE HOUSE SEWER CONNECTING TO DATE ��IC VALIDATIONS Q) B. &P. Code for the following reason PUBLIC SEWER 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 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 ,�s.�,'j,�QT 69.--71-2- fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as ITEi l^.. their sole compensation, will do the work and the structure TOTAL sTAL 9 - 30 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ CHECK 6930 El n - ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION 1 .TOTAL FEE 3D !3 i 1 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO CHANGE Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. - CONSTRUCTION LENDING AGENCY _ f I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19 , ��—`�;1�l� for the performance of the work for which this permit is OWNER OR OWNERS AGENT �fu�'•I'�,{/64 i t A f1 hH i iai f issued (Sec. 3097, Civ. C.). • --- - Lender's Name ADDRESS Lender's Address I certify that I have read th' p otion and state that the above information is Corr r o co ly with all County ordinances and State a ating PI bing and Sewers, and hereby au o " pres of this County to enter upon the a oned roperty or in ect' n pu oses. nature of miitee to _ SEE REVERSE FOR EXPLANATORY LANGUAGE