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Home My Public Portal About9638-9640 LONGDEN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION i hereby affirm that I have a certificate of consent to self insuretor'a certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800, Lob C.) CE 8€8(Rev 8/8)) APPLICATION FOR PERMIT Policy No._ Company i WORKERS'COMPENSATION DECLARATION I hereby affirm that 1 have a certificate of consent to self insure, br a certificate of Workers'Compensation 76A642D a certified copy thereof ;Sec.•3800, Lab C.) CE Insurance, or CE 808(REV.S/81 APPLICATION FOR PERMIT Policy No. Company ;Pis ❑ Certified copy is hereby furnished. + SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the;ZV'htb Ildyt g Spec COUNTY OF LOS ANGELES BUILDING AND SAFETY department. ' r Date (leant _Applicant FOR APPLICANT TO FILL IN CONNECTION DATA � �-� CERTIFICATE OF EXEM P6 N FROM WORKERS' FDECR;IPTION ING o� COMPENSAT N INSURANCE ESS W� ✓d 4'�' y' � ::', STATION DEPTH (This section need not be completed if the work involved by the "O�' UPPER permit is for one hundred dollars 0100)Or I@SS.) LOCALITY 4_ MANHOLE REFERENCE LOWER I certify that in the performance O{ the Wpfk {Of Which YhIS EST + � TYPE OF CONNECTION LENGTH FROM Y P S ST. "'�'" '_" ,-'� .,,° L`°_r' Y. CURB P.L. M.L.TOP.L. permit is issued, I shall not employ any person in any mannerso as to become subject to the Workers'Compensation Laws. P.c.No. ER � ��' CO.IMP.NO. JOB NOMAIL MA Date_. ApplicantESS `-- i I � 1y °f3P. TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, after making this Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE 9 C..,-�-- TEL.NO.Exemption, you should become subject to the Workers' ALCompensation provisions of the Labor code, you must forthwith ION LOT No,comply with such provisions or this permit shall be deemedHWY.OR S7.WIDENING revoked. TRACT a / STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION Nt9. F BLDGS. PERMIT No I hereby affirm that I am licensed under provisions of Chapter SIZF OT Now oN LOT9 commencin with Section 7000 of Division 3 of the Busi- I( 9 ) i NGS CHARGES ness and Professions Code, and my license is in full force and r , effect. CONTRACTOR �;�T. „j ; � 5>,:, _ CONNECTION CHARGE FEE License Number Lic.Class_ d ADDRESI.S - �%t REIMBURSEMENT FEE. O Contractor Date CITY J ,� ;I. �,da J• j ' '. -„ DISTRICT NO. GROUP MAP PROCESSED BY V f 6K PG i EJi am exempt under Sec. of the L.A.Co. STATE[NSE NO. d�tf .� c'...-• C ASS /►� b- Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL W HOUSE SEWER CONNECTING TO DATE 'C-' �f B. & P. Code for the followingreas y PUBLIC SEWER 6I;f , VALIDA ION .,.y SEPTIC TANK,SEEPAGE PIT OR FINA PITS AND/OR DRAINFiEID bate HOUSE SEWER CONNECTING TO BY —'�( j' PRIVATE DISPOSAL SYSTEM Signature f - i ` "'' CONNECT ADDITIONAL BLDG.OR 1 `j.7, 0 A NE -BUILDER DECLARATION WORK TO HOUSE SEWER �/ OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affi4 that I am exempt from the Contractor's License EXTN_CESSPOOL.DRYWELL,MANHOLE H s a • Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM 3� , r� ❑ 1, as owner of the property, or my employees with wages as y x their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit ❑ I,as owner of the property,am exclusively Contracting with AUTHORIZATION TOTAL FEE bill licensed 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 DWELLIN�T Tt, PUBLIC SEWER CONSTRUCTION LENDING AGENCY 4— S /' I hereby affirm that there is a construction lending agency SIGNED THIS DA F , 19 � for the performance of the work for which this permit Is OWNER OR Y' issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS � Lender's Name Lender's Address I certify that I have read this application and State that the above information is correct sl agree to comply with all County ordinances and State (ppws egulating Plumbing and Sewers, and hereby authorize/ep. sentatives of this County to enter upon b m nt Ane property for inspection pu�oses. ✓ ' ✓5+gnature of Permittee date SEE REVERSE FOR EXPLANATORY LANGUAGE ` WORKERS'COMPENSATION DECLARATION -I he eby-affirm that i have a certificate of consent to self insure, )r.q certificate'of Workers'Compensation Insurance,or 76A642D a certified copy Cher.of (Sec. 3800, Lab C.) CE 808(REV.8%$11 APPLICATION FOR PERMIT Policy No.j_. 'Company_ Ce%s ❑ Certified copy i hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the count b9ild)ng spection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. / Date Applicant _ FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXENffiTION FROM WORKERS BUILDING `,s J , T COMPENSATION INSURANCE ADDRESS '" *..y �;�. ' _g/j..��,`, ., t'�'f. �,, ... STATION DEPTH (This section need not be completed if the work involved by the LOCALITY *7-;: "'` .MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOWER NEAREST + TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS S7. ✓� .t7 _ t,> % '; Y. cuRe P.L. M.l.TOP.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. owNER r CO.IMP.NO, JNO. OB N `MAIL . Date—Applicant ADDRESS 'y J +r' Y f"��1f TRUNK PERMIT NO, ROAD PERMIT NO. NOTICE TO APPLICANT: If, after makingthis Certificate of 9 AFFiDAVTT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY ��. TEL.NO. 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 P revoked. BLOCK TRACT ,/t. STATE ENCROACHMENT O.OBIDGS. PERMIT NO. F LICENSED CONTRACTORS DECLARATION slzF of Lor Now F B LOT I hereby affirm that I am licensed under provisions of Chapter USE OF tG' 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 r effect. CONTRACTOR _ CONNECTION CHARGE FEE y� 1 - , .�� 1 � { ;'�'_. t > License Number LIG.Class ADDRESS r. 11� ti REIMBURSEMENT FEE O Contractor Date < *�"� .?, zv1 �' J,t.. DISTRICT NO./. GROUP MAP PROCESSED BY V CITY 1"s �(-�/L� TEL.NO. -Z .,,./ BK PG C-. Z ❑ 1 am exempt under Sec. of the L.A.Co. STATE �" L LIC. > 1�,1��( P LICENSE NO. __.,,..:= CLASS O 1� Plumbing Code and/or Sec. of the NO. DESCR PTION OF WORK FEE FINAL LU HOUSE SEWER CONNECTING TO DATE '-� r' VALIDATION a �/ yy B. & P. Code for the follo� PingePUBLIC ason SEWER Gl SEPTIC TANK,SEEPAGE PIT OR FINAL Z PITS AND/OR DRAINFIELD J ,.,. Date - HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature ! CONNECT ADDITIONAL BLDG.OR GC' rt h A OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER V P1 OVERFLOW SEEPAGE Pit,DRAINFIELD 1 hereby affirm that I am exempt from the Contractor's License EXTN_,CESSPOOL,DRYWELL,MANHOLE ® 6.,1 Law for the fallowing reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM --,tl ,'.y"Y 5 ❑ 1,as owner of the property,or my employees with wages as / J 0 their sole compensation, will do the work and the structure ' 7,5''0 u is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ 1, O6 -8,7 ❑ 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 Business and Professions.Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY ,r /�,. ( 2 ► I hereby affirm that there is a construction lending agency SIGNED THIS "`' DAY OF 19 t 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 lay ys regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon thp;pbq_ye-rTeyiti ed property for inspection purposes. gnature of Permittee Date _ SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION I Hereby affirm that I have a certificate of consent to self ,insum, or a certificaie of Workers' Compensation Insurance, or 7eAe42D p a certified copy thereof(Sec. 3800, Lab C. CE 808(REV.8/81 APPLICATION FOR PERMIT Policy No.- Company ®s ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the-E unty,buildi inspecti9n COUNTY OF LOS ANGELES BUILDING AND SAFETY department. 1� ,t Date Applicants bl i. � FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMj+ ION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESSl STATION DEPTH (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 t y TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this cRoss sT. / " 61"'. ,� 1^ � 1i?t;. Y. CURB P,L. M,L,To P.I. permit is issued, I shall not employ any person in any manner „ �, so as to become subject to the Workers'Compensation Laws. P.C.NO. OWNER ,,.� % �„r'" y CO.IMP.NO. JOB NO. Date Applicant ADIL TRUNK PERMIT NO ROAD PERMIT NO, NOTICE TO APPLICANT: If, after making Certificate othis f CITY TEL.NO. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE �M.,.d 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 -� STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS, PERMIT NO. I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE OF (7 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 *,t. - ? 'Y a•?. e— `. �J",7 CONNECTION CHARGE FEE � a License Number --Lic.Class ADDRESS t �1 t"��"' REIMBURSEMENT FEE O t DISTRICT NO. G UP MAP PJWCE55ED BY u Contractor Date CITY//J', p�'e.tr t ell F- TEL.NO. -" ' G t ll/ STATE LIC. f BK PG Z ❑ I am exempt under Sac. of the L.A.Co. LICENSE NO. I - CLASS "y Plumbing Code and/or Sec. of the NO DESCRIPTION OF WORK FEE FINAL ~ HOUSE SEWER CONNECTING TO DATE VALID A N LU PUBLIC SEWER �' B. & P. Code for the following reason — vhf SEPTIC TANK,SEEPAGE PIT OR -Date FINAL z PITS AND/OR DRAINFIELD n —' HOUSE.SEWER CONNECTING TO BY ��+ / /� 4 8 3 0 'a A / l �r/ ✓' PRIVATE DISPOSAL SYSTEM Signature f- H' ��wC CONNECT ADDITIONAL BLDG.OR NER-BUILDER DECLARATION WORK TO HOUSE SEWER ® °s OVERFLOW SEEPAGE PIT,DRAINFIELD r I hereby affi 0 that I am exempt from the Contractor's License EXTN..CESSPOOL,DRYWELL„MANHOLE ( g ® G 7a 5 Law for the following reason (Secton 7031.5, BUlsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure !, 0 6''8 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit s L ❑ 1, 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 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO TqE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY n' I hereby affirm that there is a construction lending agency SIGNED THIS JyAY OF14 for the performance of the work for which this permit is OWNER ORa issued (Sec. 3097, Civ. C.). OWNERS AGENT y��r i - 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 tat' laws regulating Plumbing and Sewers, and hereby outh ri representatives of this County to enter up ory b fve- tinned property for inspection purposes. ignature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WGRKERS'COMPENSATION DECLARATION �- I hereby affirm that I have a certificate of consent to self insure, or'a certificate of Workers'Compensation Insuronce, or �eA6azD a certified copy thereof ('Sec. 3600, Lab C.) CE BOB(REV B/B,) APPLICATION FOR PERMIT Policy No. _Company, (itS ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county build]rg I pection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. R ,Date Applicant y� � �' FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPT'I'ON FROM WORKERS' BUILDING Ls y� } � �j+ COMPENSATION INSURANCE ADDRESS ! +" vfs17"ZF"a l'E'%'�., STATION DEPTH (This section need not be completed if the work involved by the UPPER �+" l,:r permit is for one hundred dollars ($100)or less.) LOCALITY ` MANHOLE REFERENCE LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certifythat in the performance of the work for which this ✓ t ,� �-; �yf Y. CURB P.L. M.L.TO P.L. P cRosssr �; permit is issued, I shall not employ any person in any manner cX so as to become subject to the Workers'Compensation Laws. P.C.NO. OWNER ,�!', CO.IMP.NO. JOB NO. MAIL Date-Applicant- ADDRESS �✓ /l {, TRUNK PERMIT NO. ROAD PERMIT NO. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY / TEL.NO. 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 STATE ENCROACHMEN I '1 LICENSED CONTRACTORS DECLARATION NO,OF BLDGS. PERMIT NO r SIZE OF LOT NOW ON LOT J t� I hereby affirm that I am licensed under provisions of Chapter USE OF (V 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 +r -� `" 4'IF CONNECTION CHARGE FEE } CL License Number LIC.Class-- ADDRESS � , >.'�'�l,�k,:' %'� °'3 r[ REIMBURSEMENT FEE o Contractor Date � - DISTRICT NO. GROUP MAP P$9�ESSED BY V CITY ,r" #^.n.tS !; if'I �L.NO. Z``'.: 4/,.. ❑ I am exempt under Sec, of the L.A.Co. PTATE Llel�r J y /�X �K PG O SI CENSE NO. ,+ I CLASS H Plumbing Code and./or Sec. of the No. DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TOLU DATE..- - ,! VALIDATION I'S. B. & P. Code for the following reason PUBLIC SEWER ± y SEPTIC TANK.SEEPAGE PIT OR PITS AND/OR DRAWFIELD FIN cite HOUSE SEWER CONNECTING TO B Signature fe �,,✓ 1.�' '`�t,,..-^^"" PRIVATE DISPOSAL SYSTEM '5&3 ® „ g r CONNECT ADDITIONAL BLDG.OR x NER-BU LD R DECLARATION WORK To HOUSE SEWER J�TO ft 0 0 A s 1 0 OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, BUlsness and Pro- ALTER,REPAIR OR ABANDON HOUSE I fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I, as owner of the property,or my employees with wages as s 7, " , their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit_ S ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONBusiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SECONSTRUCTION LENDING AGENCYI hereby affirm that there is a construction lending agency SIGNED THISDAY OF for theermit is erformance of the work for which this UNNER OR slued (Sec. 3097, Civ. C.). P OWNERS AGENT ' '; ADDRESS Lender's Name Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and Sta`e laws regulating Plumbing and Sewers, and hereby authori$e r resentatives of this County to enter upon the -me6ti ed property for inspection purposes. signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE