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Home My Public Portal About5412 A & B MCCULLOCH AVE_Sewer__ WORKERS'COMPENSAXON DECLARATION 76A642D CE 808i2-80) APPLICATION FOR PERMIT I hereby affirm that Nave a certificate of consent to self SEWER-SEWAGE DISPOSAL insure, or a certificate of WorkersCompensation Insurance,or I-) a certified c(gn'thereof(Sec.3800,Lab,C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY '0 i2t Policy NfLL�LLZ Cortified co-,)y is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING STATION DEPTH T Certified copy is filed with the county building inspection. ADD R ESS UPPER department. LOCALITY MANHOLE REFERENCE R LOW ApPlicant REST NF TYPE OF CONNECTION LENGTH FROM _EROSS ST. CURB P.L. M.L. TO P.L. C.E.RF TIFICATE OEXEMPTION FRO-NJ WORKrERS' COMPENSATION INSURANCE P.C. NO OWNER CO IMP. NO. JOB NO. ' Z 7 MAIL D ESS (This section need not be completed if the work involved A DR Ise the permit is for one hundred dollar's ($100) or less.) TRUNK PERMIT NO. ROAD PERMIT NO. 0 CITY E) TEL. No. Lit-) API- WAIVER NTIRCCORD. -S-R. NC L) 1 cert if that in the performance of the work for which this LEGAL 1� X permit is issued, I shall riot employ any person in any manner DESCRIPTION LOT NO. 0 subject to the Workers' Compensa on Laws.aws. so as to become subj, HW", OR ST. WIDENING F 0, BLOCK TRACT STArC ENCROACHMENT D ate ilant I ak)" PERMIT NO. ty, Appl W�J — NO. F BLDGS. 1 1,s NOTICE '1_/7LP1PLICANT: If, after making this rAf—icate of -il—Z-1Z OF_ L Lor NOW ON LOT Exemption, you should become subject to the Workers' USE: OF CHARGES Compensation provisions of the Labor Code, you must forth- BUILDINGS with comply with such provisions or this permit shall be CONTRACTOR I—, CONNECTION CHARGE FEE deemed revoked. -,r<+' REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION A D Tj R�t I hereby affirm that I am licensed under prGvisions of Chapter 3.11 NO. MAP P ED a, TEL. NO. _C' 9 (commencing with Section 7000), of Division 3 of the Busi- CITY 'Ki LIC. �y ne, Cd STATE s and Professions ode, anmy license is in full force and LICENSE NO. CLASS ,, 11 1 11 I I effect. - WTION OF WORK FEE: VALIDATION , HOUSE EWER CONNECTING TO FINAL PU.F_1C SEWER DATE - -nI7 ) i � t Liceww Num he Lie.Class I SEPTIC TANK, SEEPAGE PIT OR PITS AN./.R FINAL HOUSE SEW—CONNECTING PRIVATE DISPOSAL SYSTEM BY ti 1 am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG,OR licensed architect or a registered professional c13 gmeer WORM TO HOUSE SE.CR -acting in my professional capacity (Section 7051, BusOVERFLOW SEEPAGE- mess and Professions Code). EXTN.,CESSPOOL, ORYWE41.,MANHOLE A LTF_R, REPAIR OR ABANDON HOUSE srW-R OR DISPOSAL SYSTEM Lie.or Reg.No..------Date—, HOME OWNER-BUlf-DER DECLARATION TOT hereby affirm that I am exempt from the Contractor's OWNEZFR'S 0 _ Permit `7 License Lava, for the following reason (Section 7031.5, Busi- AUTHORI ATI ]N AL FEE ntss and Professions Code): —a, I HAVE AT —IS DATE A CONTRACT' 4ViTH THE HEREIN NAMFO CON- ACTOR TOElCONNECT THE ABOVE DESCRIBED EXISTING DWK-IL NG f, a., owner of the property, wild do the work and the TO THE P U,OL I C SEWER. structure is not intended or offered for sale (Section SIGNED THIS —DAY OF 19 7044, Business and Professions Code). Y.Ell OR .W.EAGENT______:___ CONSI RUICTION LENDING AGENCY I hereby affirm tliLt there is a construction lending agency for the performance of the work for which this permit is issued (Sec, 301977,Civ.C.). Lender's Name— Lender's 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 herehY authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE M S, aturexofTe'rmir ee Date WORK1 RS'CONIPL'.NSATION DECLARATION '76A642D APPLICATION FOR PERMIT, CE 808 (2-80) I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL fusure, or a certificate at Workers Compensation Insurance,or acertified cony thereof(Sec. 3800,ZLab C. ) ( COUNTY OF LOS ANGELES ,f�� °^` BUILDING AND SAFETY tt Po1iLy Nd.�L r`* - �'or.-apany ® Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA SU ILD ING / "';., .:.+ gTATION DEPTH Certified copy is filed with the county building inspection ADaRr_ssi _ _ �� UPPER department. p � r � MANHOLE REFERENCE � LOC ALIT YC`. 1-r- a' � .F�-�� LOWER �� P NEAREST } / —� = ")�Y-/i T"r PE OF CONNECTION LENGTH FROM Date T_ Applicant -` _ fA CLRTIFICAYEOF'EXEMPTION`FROM WORKERS cRass sr__--� J — _` GURa P.L. M.L. TO P.L. COMPENSATION INSURANCE _ P.C. NO, OWNER i- IFI 1ti.. ,�'u-1 -i. CO. IMP. NO. JOB N MAIL ('This section nc,cd not be completed if the work involved AODRESS L yt J 1 �.Z rt Z TRUNK PERMIT NO. ROAD PERMIT NO. by the permit it for one latirtdred dollars ($100) or less.) {1 1 r /! , ,t,F'lD T WAIVER EASEMENT RECORD, I15TR, NO, DATE CL G ITY �.. f._�. YE L. NO. �-1-t V 1 _IC. 0 I certify that in the performance of the work for )which this LEGAL permit is Issued, I shall.not employ any person in:any i fanner DESCRIPTION LOT NO. HWY, OR ST. WIDENING Qe sea as to heeome sutajrect to tlic WnrktLrL' Compensation Laws. 57'AYOAM0 BLOCK TRACT L;:zte A >licant �_ NO. OF'BLDGS. PERMIT NO. L)if SIZE OF LOT NOW ON LOT NOTI I: O NPPLIC4NT: If, after making this Certificate of -- CLL Exemption, you should become subject to the Workers' USE OF Compe BUILDINGS CHARGES p provisions of the Labor Code, you roust forth- with colo.13' with such provisions or this CONNECTION CHARGE FEE p p permit shall be coNTRacroR # � a�F deemed revoked. J REIMBURSEMENT FEE LICENSED CONTRACTORS I:ECLARATION ADDRESS ��; , �� I 1 v, I DISTR'ICT NO. GR(JUP MAP PROF SSED BY I hereby affirm that I am licensed under provisions of Chapter t'j!' �r f 'CITY i,.. bt� ��..1. �... TEL. NO. 'T � .S _�('.7 � vc 9 (commencing with Section 7006) of Division 3 of the Busi- nest and Profesciom Code, and my license is in full force and STATE C. LICENSE NO. _ _ CILAss effect. Nt3. DESC RIFTION OF WORK —FEE H,)USE SEWER 111PECT'IF1G TO FINAL VALIDATION License Nurnber,/-.l f Lic.Class^� �r p Pue�l4 sEWeR t3ATE _„-.�.. SF_PTIC TANK,SE LPA aE PIT OR �. 1 (• IE PITS AND OR DRAINFL.D C°ontracto a.la-_. '. V 197te--�� I 1' _ ------- FINAL -- —� HOUSE: SEWER CONNECTIN6 TO �3Y RIVATF D SI-os SY5T.1. -_ Ia 1 am exempt from the licensing requirements as I am a CONNECT ADDITIONAL aLDG..OR licensed atclaitect or a registered professional engineer W RK TO HOUSE .L W GR acting. in m71,151, B y professional capacity (Section 5I, us- OVERFLOW SEEPAGE: PET,DRAINFIELD E.TN,,CESSPOOL,DRYWELL,MANHOLE mess and Professions Code), —. -- --. — .LYCR,REPAIR OR ABANDON HOUSE SEWER OR D{SPOSAL.SYSTEM Lie..or Reg.No._._ — Date � -- HOME OWNER.-BUILDER DECLARATION _ f. hereby affirm that I am exempt from the Contractor's OWNER'S Permit License Law for the following reason (Section 7031.5. Busi- AUTHOR I ZATI ONt TOTAL FEE J mess.and Professions Code): 1 HAVE: AT DATE A —TRACTWITH THE HEREIN_ DW- CON-TRACTOR YO CONN ECT'YHE ABOVE DESCRIB ED,F�%15TlNG DWCLLtNG 1, as. owner of the property, will do the work and the To THE PI,RLIC SEWER. structure is not intended or offered for scale (Section SIGNED THIS _DAY OF _ is 7044, Business and Professions Code). oWNCR OR OWNF-RS AGF'NT CONS"I'RUCTION LENDING AGENCY ADDRess — ------ I hereby affirm that there is a co�nE"trial-tion lending agency -- --` for the performance of the work for which this permit is issued(Sec. 3057,Civ-.C.), Lender's Name—_.--- ._.-•— -. Lender's Address—_--_.-_-- -- _-- I certify that I have real; this applicationand state that the _ above inforni.ation is correct. I agree to comply with all County ordinance; and State tails regulating Plumbing, and Sewers, and hereby authorize representatives of this County to enter uPorl the alcove-mentioned property for inspection purposes. _ SF.'E REVERSE I OR EXPLANATORY LANGUAGE ( 5 gn u ecif Perm tSEI`•, Datef�