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Home My Public Portal About10370 KEY WEST ST_Sewer__ WORKERS'COMPENSATION DECLARATION CE 808 (D2-80) APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to Self SEWER—SEWAGE DISPOSAL insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.Si.h COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company � FOR APPLICANT TO FILL IN CONNECTION DATA rUfi d copy is hereby furnished. �r / BUILDING f�L.� �o STATION -t DEPTH W Certified copy is filed with the unt buildi ADOREss s � p y g i pection /// ��yyy q -ode i�time �u� LOCALITY MANHOLE REFERENCE �j / Jj u LOWER Dates /�Applic NEAREST TYPE OF CONNECTI /LENGTH FRO CERTIFICATE OF EXEMPTIOP FROM RKERS' CROSS ST. Y. CURB P.L. M.L. TO P.L. COMPENSATION INSURANCE P.C. NO. r� OWNER CO. IMP. NO. JOB NO. MAIL (This section need not be completed if the work involved ADDRESS � / TRUNK PERMIT NO. ROAD PERMIT NO. a by the permit is for one hundred dollars ($100) or less.) �5��7 AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. DATE CITY TEL. NO. V I certify that in the performance of the work for which this LEGAL permit is issued, I shall not employ an person in an manner DESCRIPTION LOT NO. O p p y y p y FSTATE . WIDENING ' so as to become subject to the Workers' Compensation Laws. 7 0 BLOCK TRACT �C � ROACHMENT U . Date Applicant NO. OF BLDGS. W NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF LOT �fj�b� NOW ON LOT CL Exemption, USE OF _ , p you should become subject to the Workers' BUILDINGS CHARGES Z Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall beCONNECTION CHARGE FEE deemed revoked. CONTRA REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I am licensed under provisions of Chapter DISTRICT No. GROUP BK MAP PG PR OG SSE fBY 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and STATE i LIC. / 5� J� LICENSE NO. Z�S �`e CLASS ✓ �r ` effect. / NO. DESCRIPTION OF WORK FEE c�(Q� HOUSE SEWER CONNECTING TO FINAL �..-�+.'.: +' VALIDATION Licens umbers Lic. Class L / PUBLIC SEWER DATE SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD , ntY ct '✓ Date z �� FINAL / HOUSE SEWER CONNECTING TO � �� ' BY F-1 PRIVATE DISPOSAL SYSTEM F I am exem rom the licensing requirements as lam a f C CONNECT ADDITIONAL BLDG.OR v licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD mess 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 OWNERS Permit S License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE ness and Professions Code): 9051S.2 A 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING EJ1, as owner of the property, will do ttie work and the TO THE PUBLIC SEWER. D O O'O 1'O structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19 7044, Business and Professions Code). OWNER OR - 2 O - 18-0.0 OWNERS AG CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency noDREss O O O 1 0 0 for the performance of the work for which this permit is issued (Sec. 3097,Civ.C.). 0 7.2 9 —81 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 regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of;pKittee Date WORKERS'COMPENSATION DECLARATION CE 808 D-80) APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL _ insure, or a certificate of Workers'Compensation Insurance,or 7,— a certified copy thereof(Sec. 3800,Lab. C. L�MMF' COUNTY OF LOS ANGELES ( ,.o BUILDING AND SAFETY Policy o 0 any f-�GI��A ❑ Cert ied�`� I rebby�urnis FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING STATION DEPTH Certified copy is filed with u bu' ing inspection ADDRESS UPPER MANHOLE REFERENCE e� rr}��}��nt�,� J LOCALITY LOWER Dat S� 4pllcant �(r NEAREST TYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXE PTION FROM WORKERS' CROSS ST. Y. CURB P.L. M.L. TO P,L. COMPENSATION INSURANCE P.C. NO. OWNER CO. IMP. NO. JOB NO. ` MAIL ryry T (This Section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO v 3_ 71" 8 by the permit is for one hundred dollars ($100) or less.) '2 L66 V j AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE CITY TEL. NO. I certify that in the performance of the work for which this LEGAL ru� ccO permit is issued, I shall not employ any person in any manner DEsc RIPT%ON LOT NO. HWY. OR ST. WIDENING e / LjJ f. so as to become subject to the Workers' Compensation Laws. V BLOCK TRACT STATE ENCROACHMENT LU Date Applicant i{ Q O. OF BLDGS. PERMIT NO. (Z SIZE OF LOT JG _`NOW ON LOT NOTICE TO APPLICANT: If, after making this Certificate of .. (� /S Z Exemption, you should become subject to the Workers' USE OF Compensation BUILDINGS D CHARGES p provisions of the Labor Code, you must forth- CONNECTION CHARGE FEE with comply with such provisions or this permit shall be CONTRACTOR deemed revoked. ADDR LICENSED CONTRACTORS DECLARATION Ia REIMBURSEMENT FEE ESS I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP MAP PROCESSED BY 9 (commencing with Section 7000) of Division 3 of the Busi- CITY TEL. No. BK PG ness and Professions Code, and my license is in full force and STATE Llc. 9�p' SC S? ? effect. LICENSE NO. CLASS O llr� No. DESCRIPTION OF WORK FEE ZHOUSE SEWER CONNECTI G T /�/ FINAL VALIDATION License Number2 4��+2 Lic.Class GI PUBLIC SEWER Q� DATE SEPTIC TANK,SEEPAGE PIT OR �� ` Jt, / PITS AND/OR DRAINFIELD COntr C i Date `lff// lJ ` FINAL (G HOUSE SEWER CONNECTING TO BY El 'J I x rom PRIVATE DISPOSAL SYSTEM a licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR llc sod architect or a registered professional engineer WORK TO HOUSE SEWER ting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN.,CESSPOOL,ORIWELL,MANHOLE mess and Professions Code). 2 ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNERS Permit S p License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION I TOTAL FEE L go qq /, Ll ness and Professions Code): , HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- Z b 2 0 A YRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING EJ I, as owner of the property, will do the work and the TO THE PUBLIC SEWER. structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19 # o O'o D 10. 7044, Business and Professions Code). OWNER DR OWNERS AGENT 2 0 0 22,50 CONSTRUCTION LENDING AGENCY ADDRESS ' I hereby affirm that there is a construction lending agency D'D ox 2250 for the performance of the work for which this permit is , issued (Sec. 3097,Civ.C.). o`6 2'8_82 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 regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Permitt 71, Date