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Home My Public Portal About8905 LAS TUNAS DR_Sewer__ WORKERS'COMPENSATION DECLARATION ereby affirm that I have a certificate of consent to self W..:1:111,cy re, or a certificate of Workers'Compensation Insurance, or 76A642D rtified co y thereof Sec 3800 b C.) p CE 808(REV B/Bi) APPLICATION FOR PERMIT N ompany Ir(G Os ❑ Certified copy is hereby furnished. �1 / — SEWER - SEWAGE DISPOSAL , ❑ Certified copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY dejartment.p Date '??—O Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKER BUILD INGO STATION DEPTH COMPENSATION INSURANCE ADDRESS (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 , v'! / . LOWER S I certify that in the performance Of the work for which this CROSSST TYPE OF CONNECTION LENGTH FROM Y CURB PL ML TOPL Y' permit is Issued, I shall not employ any person in any manner C NO so as to become subject to the Workers'Compensation Laws. OWNER 4107 5AfVQZS' Qe� CO IMP NO JOB NO MAIL15 TRUNK PERMIT NO ROAD PERMIT NO 49 Date Applicant ADDRESS '— AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE O NOTICE TO APPLICANT- If, after making this Certificate of CITY TEL NO V Exemption, you should become subject to the Workers' LEGAL gotU Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO HWY OR ST WIDENING IL comply with such provisions or this permit shall be deemed 11A revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NOSIZE 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 J� /� CONTRALTO CONNECTION CHARGE FEE License Number iC47 ' Lic.Class `lf0 Y ADDRESS (IT i:n REIMBURSEMENT FEE Contractor L&H A i "O TfC1%Date CITY L TEL NO ZS DISTRICT NO GROUP MAP PROCESSED BY BK PG STATELIC 0 El am exempt under Sec. of the L.A.Co LICENSE NO CLASS` - J Plumbing Code and/or Sec. of the NO DESCRIPTION OF WORK FEEL HOUSE SEWER CONNECTING TO DATE VALIDATION B. 8 P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL Dale HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR 00. O NER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I•am exempt from the Contra is License EXTN,CESSPOOL,DRYWELL,MANHOLE E Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM 9 3 7 A ❑ j, as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure ;;' 0 0 0 0 1 0 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit $ 1 1,50 ❑ j, 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 iC 1 1' 5 0`6 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCY (I 0 2—8 1< I hereby affirm that there is a construction lending agency SIGNED THIS D F f 19 oil the performance of the work for which this permit is OWNER OR Issued (Sec. 3097, Civ C.). OWNERS AGENTADDRESS 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 jaws regulating Plumbing and Sewers, and hereby authorize representativ sof this C my to enter upon ve- bonepro t ins p n purposes Signature of Permittee ate SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION ry I hereby affirm that I have a certificate of consent to self Insure, or a certificate of Workers'Compensation Insurance, or 76A642D a certlfiec�copy they a (Sec 3800, Lqk C ) 9 / / X508(REV 8/81, APPLICATION FOR PERMIT Policy N&C60 Company ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING C 7 STATION DEPTH COMPENSATION INSURANCE ADDRESS �7 ?V (This section need not be completed if the work involved by the �T` MANHOLE REFERENCE UPPER LOCALITY c..� permit is for one hundred dollars ($LOO)Or 1055.) NEAREST TYPE OF N LENGTH FROM I certify that in the performance of the work for which this CROSS sT CS L✓� YCUR P L ML TO P L permit is issued, I shall not employ any person in any manner EL so as to become subject to the Workers' Compensation Laws P c NO I p OWNER ILiI,E �j hG)�� CO IMP NO 3 0 JOB NO V MAIL TRUNK PERMIT NO ROAD PERMIT NO p� Date Applicant ADDRESS � �� AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE O NOTICETO APPLICANT. If, after making this Certificate of CITY TEL NO � Exemption, you should become subject to the Workers' LEGAL LUV 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 BUST- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. irr 7� /7 �/ CONTRACTOR y✓L CONNECTION CHARGE FEE License Number 7f'd`f' Lic Class C '--L-2— ADDRESS !Ig -7 ® / �/ — REIMBURSEMENT FEE Contractor ICJ//)7�0MXt.te 6 -2-3-93 CITY LC- GZ.1�- TEL No 2.9 '3 (p�nGlcflJ DISTRICT NO GROUP BK MAP PG PROCESSED BY El am exempt under Sec. of the L A.Co. LICENSE NO cLA55 ' Plumbing Code and/or Sec. of the NO DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE VALIDATION PUBLIC SEWER -Off"•- B & P. Code for the following feOSOn SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD �\ Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature eCONNECT ADDITIONAL BLDG OR , /' ^ �1 n A OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER 4/� / Y p OVERFLOW SEEPAGE PIT,DRAINFIELD }, I hereby affirm that I am exempt from the Contractor's License EXTN,CESSPOOL,DRYWELL,MANHOLE {�� o 0 0 0 1 0 Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM 2'-.- 2 7-5 0 ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure o - 27,506 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ p o S 2 3—8 3 ❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE j{J licensed contrbctors 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 OF 19_ for the performance of the work for which this permit is OWNER OWNERS AGENT issued (Sec 3097, Civ C ). 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 ordinances and State laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon a Ove- ention ropers pectj n urposes Signature of Permittee SEE REVERSE FOR EXPLANATORY LANGUAGE