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Home My Public Portal About9468 LA ROSA DR_Sewer__ i WORKEFS'•COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self tI insure, or 9 certificate of Workers'Compensation Insurance, or 76A642D ys U a,certified copy thereof (Sec, 3800 Lab C., TCE808(REV 1,83) APPLICATION FOR PERMIT Policy No. Company" is 2 ��LrTJ ❑ Certified copy is hereby furnished. 'b Z.$,S SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY de rtment ^_ l DatApplicant // /j'� FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING (` _ STATION DEPTH COMPENSATION INSURANCE ADDRESS J (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 LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST Y CURB PL ML TOP L permit is Issued, I shall not employ any person In any manner so as to become subject to the Wis,Compens�a(`10 Lows OWNER / CO IMP NO JOB NO /� MAIL TRUNK PERMIT NO ROAD PERMIT NO Date-i/�/—/��%/—Applicant ��//L((/�� ADDRESS NOTICE TO APPLICANT If, after making t4is Certificate of CITY f EL NO AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE Exemption, you should become subject to the WorkersLEGAL 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 J11J CONNECTION CHARGE FEE License Number LIC.Class 46 / ADDRESS - A REIMBURSEMENT FEE R (� J� r Contractor{/�'1< ��•bate 9—/ .3'6-7-7 � n , DISTRICT NO GROUP MAP PR ESSED BY O CITY w ��.�VJ TEL NO L C, f/(y R 1 BK PG W ❑ I am exempt under Sec. of the L.A.Co STATE LICENSE NO a CIAss `"J1 (�D ./) 1V ItYi NO DESCRIPTION OF WORK FEE lJ O Plumbing Code and/or Sec. of the HOUSE SEWER CONNECTING TO FINAL /�� r VALIDA ION ci PUBLIC SEWER LL�� B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR d PITS AND/OR DRAINFIELD FIN N Date HOUSE SEWER CONNECTING TO B PRIVATE DISPOSAL SYSTEM / Signature CONNECT ADDITIONAL BLDG OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER 11 00 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, BUjsness and Pro- ALTER,REPAIR OR ABANDON HOUSE D r� n fessions Code)' SEWER OR DISPOSAL SYSTEM Z 2 621 A ❑ 1, as owner of the property, or my employees with wages as #.0 o,o 0.1 Q their sole compensation, will do the.work and the structure is not intended or offered for sale (Section 7044, Businesso o 2 1 5 O and Professions Code). OWNER'S Permit' S ❑ I, as Owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO O 2 6 O Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCY , 0a08"85 I hereby affirm that there Is a construction lending ,agency SIGNED THIS DAY OF 1 for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C ) OWNERS AGENT r �� , / Lender's Name (� ADDRESS 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 I ordinances and State laws regulating Plumbing and Sewers, and hereby,authorize representatives of this County to enter upon above-mention rap for spection purposes( Ignoture ofmitre Date SEE REVERSE FOR EXPLANATORY LANGUAGE ly ti 1 CJi'Ej DEPA1tTMENT OF COUNTY ENGINEER SEWER--SEWAGE DISPOSAL 1 DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEER I BUILDING ADDRESS FOR APPLIC�NT FILL IQ LOCALITYUfLDING NEAREST ADDRESS /, _ J ^TT�� CROSS ST. LOCALITY '" DISTRICT NO. SERIAL NO. PERMIT NO. NEAREST A �� // �� S CROSS ST. /� - REQEIBY Ready for laaoeetion ISSU�� OWNER MAIL USE ZON OCCUPANCY CIIaA " ADDRESS �-a SL� BK PG CITY TEL.NO. CONTRACTOR Q (�'eEk :LeiCO.IMP.N0. 3 ADDRESS JOB NO. CITY TELAO. SI 3 TRUNK PERMIT N0. ITATE REGISTRATION N0. / 3 - / COUISTN ROAD PERMIT N0. LEGALSTATE ENCROACHMENT DESCRIPTION LOT NO. �� PERMIT N0. -- BLOCK TRACT 3 � INDUSTRIAL WASTE APPROVAL SIZE OF LOT � NO.OF BLOCS.x �Y is NOW ON LOT CHARGES USE OF BUILDINGS CONNECTION CHARGE FEE NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE PUBLIC SEWER @ $ 3.50 sv RECEIPT NO. DA I BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OREXCEPTIO RECORD WORK TO HOUSE SEWER 1.00 ALTER OR REPAIR EXISTING - NO I DATE BY SEWER OR DISPOSAL SYSTEM 1.00 DISCONNECT AND ABANDON SEWER CONNECTION DATA AND/OR DISPOSAL SYSTEM 1.00 SEPTIC TANK,SEEPAGE PIT OR c PITS AND/OR DRAINFIELD 2.00 STATION /� 3 i�J DEPTH CESSPOOL—DRYWELL i —SPECIAL CONDITIONS ONLY 2.00 / ANHOLE REFERENCE I LOWER M� TYPE OF CONNECTION LENGTH FROM r OWNERS PERMIT 1 00 �CUm Z. M.L.TO P.L. AUTHORIZATION I TOTAL FEE ,f 7!e 74� 1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED 'CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE• DWELLING TO THE PUBLIC SEWER SIGNED THIS.__�_�......DAY OF........ 4 :..:___...jgto NEW HOUSE SEWER ��/ A'*�l OWNER OR CONNECT ADDITIONAL OWNERS AGENT. n__! x_v.-/-..0-\ L�-_....______._ BUILDING OR WORK G SEPTIC TANK,SEEP.PIT(S) ADDRESS....._/-�z ___CkA.,/.L`/!�-I`-------..-_.....--.-.-- AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI. CESSPOOL 0 DRYWELL E] CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE ' TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR.SEWER OR REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑ SIGNATURE -�� SEEP.PIT(S)[] CESSPOOLS, /Q -s-- OF PERMITTEE.. / 70A042D 663 1/53 A�