Loading...
HomeMy Public PortalAbout5761 LOMA AVE_Sewer__ .1 } VORKERS'COMPENSATION DECLARATION I herebylcffirm that I have a certificate of consent to self insure, ora certificate of Workers'Compensation Insurance, or 76A642D a certified,copy thereof (Sec. 3800, Lab C.) CE808(REV.8/81) APPLICATION FOR PERMIT Policy No. Company ©s ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the c unty building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY dep rime t. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGSTATION DEPTH COMPENSATION INSURANCE ADDRESS V-7 Lo ma (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 to TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.I.TO P.L. permit is issued, I shall not employ any person in any manner so as t bec me subject to the Work Compens do Laws. t P.C.NO. OWNER CO.IMP.NO. JOB NO. MAILILE) TRUNK PERMIT NO. ROAD PERMIT NO, Date Applicant ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of CITY.�le,VVIIL.NO. ® AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE 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 L4 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 CONNECTION CHARGE FEE License Number LIC.Class REIMBURSEMENT FEE ADDRESS t O Contractor Date DISTRICT NO. GROUP MAP PROCESSED BY CITY _ TEL.NO. BK PG c� El am exempt under Sec. of the L.A.Co. STATE / LIC. ;/J� O P LICENSE NO. CLASS jX Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO DAT VALIDATI N PUBLIC SEWER B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR Date PITS AND/OR DRAINFIELD HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR / (f 1, ► 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, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Cade): - SEWER OR DISPOSAL SYSTEM ;{f X,as owner of the property,or my employees with wages as s_ _ their sole compensation, will do the work and the structure vz is not intended or offered for sale (Section 7044, Business 9 c and Professions Code). OWNER'S Permit $ ._3=(1 21.5- ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE f i F EMS Iicensed.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. ;e i ESL _ 50 CONSTRUCTION LENDING AGENCY .A-.•• r �=�V; I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ 0111111", =•11=` for the performance of the work for which this permit is ownNER°acEnT '-_ H13� a! El issued (Sec. 3097, Civ. C.). ADDRESS Lender's Name Lender's Address _I_1IXI—W!11 s.' a�,�_. AN I certify that I have read this application and state that the !!. .=k�= above information is correct. I agree to comply with all County 375 ordinances and State laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon e above- do ed )perty for in ecti n purposes. rM F Signature of Permittee Uate SEE REVERSE FOR EXPLANATORY LANGUAGE DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1 DIVISION OF BUILDING-AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX. COUNTY ENGINEER BUILDI ADDRESS �A / NG CASSATT D. GRIFFIN, SUPT of BUILDING FOR APPLICAN TO- F14L, IN NEAREST 7"�o ,,��� CI , BUILDING NEAREST / ® `/ ADDRESSL�,�a� i / T CROSS T. ,* _s & "as q LOCALITY �� DISTRICT NO. SERIAL NO. 1PE�R?MIT NO. NEAREST - A i 73 f GAJ ai'IT+�' S CROSS ST. P.ECEIIV� Ready for inspection DATE ISSUED OWNER ) -'27-.S� AMAILDDRESS j� USE ZONE OCCUPANCY MAP BK PG CITY TEL.NO. CONTRACTfT / ��0� ?rsw �,� , CHARGES REIMBURSEMENT FEE ADDREYSS REQUIRED --� CITY J . / NOT REQUIRED-­­-!:--' d � 9 TEELL.NO. d�l ,JOB NO. -�-q�9"� ., CONNECTION CHARGE FEE REGlSTRA ON NO.�� STATE .3 V �j C UNTY CO.IMP. N0. _z 72 - � RECEIPT N0. DATE �I BY LEGAL DESCRIPTION LOT N0. BLOCK TRACT / WAIVER FOR RECORDING SIZE OF LOT X N0.OF BLDGS. ' ..) RECEIPT-NOt "I DATE BY NOW ON LOT yi► USE OF BUILDINGS TRUNK PERMIT NO. NO. DESCRIPTION OF WOOY FEE y PHOUSE SEWER UB IC SEW RCONNECTING TO @ $ .3.50 ROAD PERMIT NO. ` 7 ..L HOUSE SEWER CONNECTING TO STATE ENCROACHMENT,, =---_- PRIVATE DISPOSAL SYSTEMI.00 I PERMIT NO. CONNECT ADDITIONAL BLDG.OR I INDUSTRIAL - x — WORK TO HOUSE SEWER I.00 WASTE APPROVALY ALTER OR REPAIR EXISTING SEWER OR DISPOSAL SYSTEM 1.00 I CONNECTION DATA DISCONNECT AND ABANDON SEWER J / AND/OR D.ISPOSAL SYSTEM 1.00 I STATION 14 O DEPTH , SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD 2.00 I MANHOL RE ERENC CESSPOOL—DRYWELL UPPER LOWER SPECIAL CONDITIONS ONLY 2.00 I TYPE OF CONNECTION LENGTH FROM "i CURB M.L.TO P.L. OWNERS -PERMIT $ I 1 -, 00 AUTHORIZATION I TOTAL FEEIHAVE THIS DATE 4 a G N NAED CONTRACTOR TO CONNECT THTE ABOVE DESCRIBEDED WITH THE EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE DWELLING TO THE PUBLIC SEWER SIGNED THIS-------------------DAY OF`':'_..............----- 19 NEW HOUSE SEWER Pe ,f CONNECT ADDITIONAL OWNER OR �/7 (}�J� BUILDING OR WORK OWNERS AGENT _L ..°/. �1 SEPTIC TANK,SEEP.PIT(S) ADDRESS--------------- - ........ - AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT.I HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL I] CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR SEWER REGULATING PLUMBING AND SEWERS.- SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND AND/OR LICENSED;AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT ABANDON HOPLUG PLUGUSE AND AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- EWER ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS 0 SEEP.PIT(S) CESSPOOLS SIGNATURE /J --- OF PERMITTEE.-a'l -' _ ...................................... 76A642D _663