HomeMy Public PortalAbout9501-9503-9505 LONGDEN AVE_Sewer__ wORh=1 RS'f-CJM} ysATrON L)E;CLAR,a rroN 76CE gos(D2-80) APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self SEWER-SEW�. E DISPOSAL
insure,or a certificate of Workers'Compensation Insurance,or
a cert i/f.edLco thereof(Sec. 380q, .,S,) r COUNTY OF LOS ANGELES,- _ t BUILDING AND SAFETY
Policy to.- Company G4;ref ry I�4 L, .dfFa. C a
FOR APPLICANT TO FILL IN CONNECTION DATA
1,9 Certified copy is hereby furnished. / r _
d' BUILDING -,.. �� STATION - �a G� DEPTH
iyCertified ADDRESS
lpy is filed with the county building inspection 'department. LOCALITY MANHOLE REFEREN ms
.®✓;3� _,
OWER
Dare Applicant INEARESTTYPE OF CONNECTION LENGTH FRO
CROSS ST. -' `-"`.., Y. CURB P.L. M.L. TO P.L.
CERTIFICATE OF
'EXEMPTION FROM 4NORIt'L:RS' a v mr
COMPENSATION INSURANCE owxER . fi d. �° ;,�. CO. IMP. NO. '� f J B NPC O
M AIL 'r,sem/' .
iM�(�LLThis section iter'.d not be completed if the work involved .ADD.E33 �` ', x�,� Y` p?,I �,,1-C- TRUNK PERMIT NO. r� ROAD PERMIT NO. �
f;VJ' the permit is for one hundred dollars ($100) or Less.) -+,�fsn' A—IIyDAVIT R ABiMGeLT RECORD.IN9TR.NO. DATE o
C.. CITY I Ems:'..d7, � TEL. NO- ,d' A �q[ 9,- s- 0 U'
I certify that in the performance of the work for which this LEGAL F �
:permit is issued, I shall not Employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING X
so as to become subject to the Worker's' Compensation Laws.
(BLOCK TRACT STATE I- ROACHMENT
aIe Applicant ZC
NO. OF BLDGS. PERMi O.
SIZE OF LOT NOW ON LOT
OTICE TO APPLICANT: If, after making this Certificate of e'""`�✓, yJ -
;xemptinn, you should become subject to the Workers' BUILD NOS CHARGES �
:;Compensation provisions of the Labor Code, you must forth-
uith comply with such provisions or this permit shall be coNraECTlox CHARGE FEE
de rued coxTRAcroR
revoked. t ; '„
REIMBURSEMENT FEE
6 LICENSED CONTRACTORS DECLARATION ADDRESS
F CITY TEL. NO,
I hereby affirm that I am licensed tinder provisions of Chapter ! 4A DISTRICT NO, ED
GROVP MAP PROC SBY
I ...� f y.
r 9 (commencing with Section 7000}of Division 3 of the Busi- C/
;r ness and Professions Code,and my license is in full force and STATE LIC. �! r$'� /�p (��p
LICENSE NO. CLASS ��.
effect. _ No. DESCRIPTION OF WORK FEE
FINAL
HOUSE SEWER CONNECTING TO � �.• VALIDATION
�
License Number Lie.Class PUBLIC SEWER z DATE
SEPTIC TANK,SE EPAGF_ PIT OR
PITSAND/OR DRAINFIELD FINAL.
Contractor Date ——----
HOUSE SEWER CONNECTING TO BY �„�.,
PRIVATE DISPOSAL SYSTEM `��
I ant exempt from the licensing requirements as I am 3 CONNECY ADDITIONAL BLDG.OR
licensed architect or a registered professional engineer WORK TO HOUSE. SEWER
BC f ! 1
acting in my professional Capacity (Section 7051, us- OVERFLOW SEEPAGE PIT, DRAINFIELD X115 /
-TN_CESSPOOL,DRYWE'LL,MANHOLE
mess and Professions Code).
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic.or Reg.No. Date_ 4
HOME OWNER-BUILDER DECLARATION 4r .`7 f-)
I hereby- affirm that I am exempt from the Contractor's OWNER'S Permit
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION1 TOTAL FEE d
tress and Professions C:ode):
1� i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
}t.
i CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBE. EXISTING DWELLING `�I 1, as owner o.c 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
7044, Business and Professions Code). OWNER OR
OWNERS AGENT
CONSTRUCTION LENDING AGENCY ADDRESS
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
[gsucd(Sec. 3097,Civ,C.).
Lender's Name
L'ender's Address--
I
ddress _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 herebv authorize representatives of this County to enter
upoit thL akf,ve It elkeoned p >re to for inspection purposes
F
SEE RIsVF,RSE FOR EXPLANATORY LANGL'AC;I:
'c Signature of Permittee Date