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Home My Public Portal About9588 LOWER AZUSA RD_Sewer__ ti. WORKERS COMPENSATION DECLARATION 92-0002 DPNH-3/87' 4 I hereby affirm that I have a certificate of consent to self 76A642D Insure or a°cceertificate of Workers Compensation Insurance or CE BOB a certified o y-- thereof(Sec 3800 Lab C ) APPLICATION FOR PERMIT 1 —'0 ®s L Certified copy Is hereby furnished / d- SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department 1 ntt Dote 1117-1111 Applicant 1AJMt' W dt-wcrFB FOR APPLICANT TO FILL IN CONNECTION DATA CER IFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE 8 4p Lo�- ZSTATION DEPTH (This section need not be completed if the work Involved by the MANHOLE REFERENCE OR permit is for one hundred dollars ($100)or less ) Ic TYPE OF CONNECTION LENGTH FROM I certify that In the performance of the work for which this Y CURB P L MIL TOP L r permit Is Issued I shall not employ any person In any manner PC NO so as to become subject to the Workers Compensation Laws OWNER CO IMP NO JOB NO MAIL TRUNK PERMIT NO ROAD PERMIT NO Date Applicant ADDRESS AFFIDAVIT I 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 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 u5E 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 � T CONNECTION CHARGE FEE /S } License Number 5.77J LIC Class C__q Z_ ADDRESS �z �j� REIMBURSEMENT FEE O Contractorttjth�o� Date CITY TEL NOCZ) g r 1-2-7 J Z DISTRICT NO GROUP MAP PROCESSED BY O STATE LIC [ BK PG Z of the L A Co LICENSE NO CLASS C— Z 4 El I am exempt under Sec (~j Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO O DA Ej� _ VALIDATION a B 8 P Code for the following reason PUBLIC G / 6 SEPTIC TANK SEEPAGE PIT OR y PITS AND/OR DRAINFIELD FINAL Z Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR Poo. BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT DRAINFIELD I hereby affirm that I am exempt from the Contractors License EXTN CESSPOOL DRYWELL MANHOLE Low for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE fessions Code) SEWER OR DISPOSAL SYSTEM P L T.a ❑ 1 as owner of the property or my employees with wages as il��f c r_ their sole compensation will do the work and the structure _ is not intended or offered for sale (Section 7044 Business OWNERS Permit $ I I)EM IS and Professions Code) ❑ 1 as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE 166 K7�5 T'{TAE 66.Te,F 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 THE PUBLIC SEWER C HEti . ellL C` CONSTRUCTION LENDING AGENCY �� 19� , "HANGS ,f fit I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF OWNER OR for the performance of the work for which this permit is OWNERS AGE 1 issued (Sec 3097 Civ C ) Lender s Name ADDRESS a Lender s Address 129 f 1 Ari 9'it, 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 the above mentioned property for inspection purposes �Slgnatfe o Permitt D te�o Permitt D tee SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS COMPENSATION DECLARATION % • 9 A 3/87 �1 hereby affirm that I have a certificate of consent to self 76A642aAeazD A Insure or a certificate of Workers Compensation Insurance or CE 808 a certified copy thereof(Sec 3800 ..abC) APPLICATION FOR PERMIT Policy No 6 ComPony ®s 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 r ,�f Date l�2MI Applicant Gt/.,� �/E�-r s�/ — FOR APPLICANT TO FILL IN CONNECTION DATA CER¢IFICATE OF EXEMPTION FROM WORKERS BUILDING COMPENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed If the work involved by the -?" Y MANHOLE REFERENCE UPPER permit is for one hundred dollars($100)or less ) LOCALITY LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that In the performance of the work for which this CROSS 5T ir..r Y CURB P L ML TOPI. permit Is Issued I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws OWNER CO IMP NO JOB No MAIL TRUNK PERMIT NO ROAD PERMIT NO Dote Applicant ADDRESS NOTICE TO APPLICANT If after making this Certificate Of CITY TEL NO AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE Exemption you should become subject to the Workers Compensation provisions of the Labor code you must forthwith DESCRIPTION LOT No P P Y 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 LOT USE OF GG 9 (commencing with Section 7000) of Division 3 of the Busl BUILDINGS CHARGES ness and Professions Code and my license Is in full force and effect �i CONTRACTOR CONNECTION CHARGE FEE License Number J!i'7 Llc Class ADDRESS REIMBURSEMENT FEE 0 1 11t Contractor dt- Date 7 CITY TEL N " DISTRICT NO GROUPMAP PROCESSED BY V BK PG Z ❑ 1 am exempt under Sec of the L A Co LICENSE NO CLASS Z d'a p a a;- -L I L NO DESCRIPTION OF WORK FEE R Plumbing Code and/or Sec of the FINAL i +�+ V PUBLIC E SEWER CONNECTING TO DATE ,g V LIRA LU B 8 P Code for the following reason ap-x SEPTIC TANK SEEPAGE PIT OR �- .._B'' c _6 PITS AND/OR DRAINFIELD FINAL Date HOUSE SEWER CONNECTING TO BY4 C PRIVATE DISPOSAL SYSTE �� 1,5'k 101 Signature CONNECT ADDITIONAL BLDG OR i Hjt3t f OWNER BUILDER DECLARATION WORK TO HOUSE SEWER ► �! I I hereby affirm that I am exempt from the Contractors License OVERFLOW SEEPAGE PIT DRAINFIELDEXTN CESSPOOL DRYWELL MANHOLE Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE f � g c n fessions Code) SEWER OR DISPOSAL SYSTEM s03 MG1 1i,r -,(;1 ❑ I as owner of the property or my employees with wages as ' JW042 4L 025 fy IT" 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 I TOTAL FEE d0 licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ACONTRACTOR TO Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCY /r_ / _ �� ► I hereby affirm that there Is a construction lending agency SIGNED THIS DAY O r///,_=/ 19_ for the performance of the work for which this permit Is OWNER OR issued (Sec 3097 Civ C ) OWNERS AGE 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 repretentatives of this County to enter upon the above ntione roperty for inspection purposes // 5 71 f Si q0ture of P it ate SEE REVERSE FOR EXPLANATORY LANGUAGE