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Home My Public Portal About9361 LOWER AZUSA RD_Sewer__ WORKERS'COMPENSATION DECLARATION 1 hereby affirm that 1 have a certificate of consent to self insure, or o certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof(Sec. 3804, L6b C.)` 82-0002 DPW 6/88 APPLICATION FOR PERMIT Pc�hcy o a� z [`�errff�dca'py i"s tSeNy furnished. SEWER - SEWAGE DISPOSAL ° ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. yrs\ Date 5—It-RC) Applicant� �{at�y,E e CXFOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS ..t„� A STATION �. EPTH (This section need not be completed if the work involved by the 4 ! ; MANHOLE REFERENCE permit is for one hundred dollars ($100) or less.) LOCALITY , L ! LOWER I certifythat in the performance of the work for Which this NEAREST ++ C TYPE OF CONNECTION LENGTH FROM p CROSS ST. L--�J�('-'�� 4,1 Y, CURB P.i. M.L.TO P.L. permit is issued, I shall not employ any person in any manner r� so as to become subject to the Workers' Compensation Laws. OWNER T `i CO IMP,NO, JOB NO. MAIL �q ,"(�`' - TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicont ADDRESS iLL_ Y NOTICE TO APPLICANT: If, after makingthis Certificate of rV<3 � AFFIDAVIT WAIVER EASEMENT RECORD.INSTIL.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. 1 7 HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed rr�� revoked. BLOCK G-+ ! TRACT a SI ATE ENCROACHMENT LICENSED CONTRACTORS DECLARATIONNO.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 g effect. '"� �/y� CONTRACTOR G l � � � CO^tNECTPON CHARGE FEE License Number h�` lgh Lic.Class �'/ ADDRESS 35 0 1 ° C REIMBURSEMENT FEE r� L v �[ DISTRICT NC. GROUP MAP PR ESSEU BY Contractor pte 7 �'( �t CITY t 4<( " o ;,1 0 LAJBK PG ,M ❑ I am exempt t under ec. of the L.A.Co. STATE LtC. j b p LICENSE NO. f CLASS --,> ', r D SCR PTION OF WORK FEE LAJ Plumbing Code and/or Sec. of the NO. FL AL i d: HOUSE SEWER CONNECTING TO DATE S �/AL ATION to B. &P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR FINAL Z PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR 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 F{p Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE y 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 is not intended or offered for sale (Section 7044, Business •.m. and Professions Code). OWNER'S Permit $ ' ❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE AL 167 01 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C NT CT R TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLI SEWER. ""HECK., CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 14_ for the performance of the work for which this permit is rwrvER OR slued (Sec. 3097, Civ. C.). OWNERS AGENTADDRESS k 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 epresentatives of this County to enter upoq the above-menti ned property for inspection�purposes. _ gnature of Per 'ttei3 %4D.te SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION I 1-a,r-4by a+firm ihat,l have a certificate of consent to self jr-sure,sor a certificate,of Workers'Cpmpensation Insurance; or rsnsazD ;6 certified copy thereof (Sec. 3800, Lab C,f 9Z0002DPW 6/88 APPLICATION FOR PERMIT Policy No. Company ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL r i ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. bate Applicant_ FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' fNEAREST DIN / s ArtoN DEPTH COMPENSATION INSURANCE RESS �� -3 .+ (This section need not be completed if the work involved by the ALITY — lr PMNHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) 1 / _ LOWER d� TYPE OF CONNECTION LENGTH FROM certify that in the performance of the work for which this SS ST. /TSL v CURB P L. M.L.To PA. permit is issued, I shall not employ any person in any manner - so as to become subject to the Workers'Compensation laws. ""* p '7 _ P.C.NO. I P OWNER f� rl /�/4?�, - CO.IMP.NO. JOB NO. /'/ ADDRESS ? e a TRUNK PERMIT NO. ROAD PERMIT NO. Dal e - E � Applicant/ '-�/ lL� ( MAIL NOTICE TO APPLICANT: If, after making this Certificate of -. AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO DATE 1 Exemption, you should become subject to the Workers' CITY 8C pL t"'r TEL.NO. �� 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 - -` ,TATE 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 -7 usE of �r 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS 4- v-jC_ _ CHARGES j ness and Professions Code, and my license is in full force and ^effect. �� ,,.r CONTRACTOR C�jr� �- e,°f't el,,�" CONNECTION CHARGE FEE License Number Lic.Class ADDRESS1�5f i L,17 ( 0 4'iT REIMBURSEMENT FEE r a Contracto Date �Y DISTRICT NO. G UP MAP PROCESSED BY � .. ..-- CITY e .. sc.. 1.NO. p T^�+ ! gIF BK PG y., TATE ❑ I am exempt under Sec. of the L.A,CO. LICENSE NO. - 1c,"ASS L Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL - U HOUSE SEWER CONNECTING TO DATE' VALIDATION ca- 8. 8 P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FINAL '' O PITS AND/OR DRAINFIELD BY {` Date HOUSE SEWER CONNECTING TO Iv LTJ PRIVATE DISPOSAL SYSTEM CL Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License EXTN.,C SSPOOL,DRYWELLL,4INFIELMANHOLE F Law for the fallowing reason (Becton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ❑ 1,as owner of the property,or my employees with wages as 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 $ ❑ ',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 Rao Business and Professions Code). CONNECT THE ABOVE DE ( EXISTING DWELLING TO THE PI SEWER, sj a. CONSTRUCTION LENDING AGENCY hereby affirm that there is a construction lending agency SIGNED THIS 19_L� for the performance of the work for which this permit is OWNER OR OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS Lender's Name t Lender's Address I certify that I have read this application and state that the W1�0 above information is correct. I agree to comply with all County i ordin c s and State lows regulating Plumbing and Sewers, and er by authori r preseatatives of this County to enter i„up th/ above a ed property for inspe,;t n purposes. Signature o ermittee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE