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HomeMy Public PortalAbout5414 A & B MCCULLOCH AVE_Sewer__ t,4C RKFR.S''CC)MI'I.NSATIC)N DECLARATION 7fiA642D APPLICATION FO PERMIT R M I 1 Gi= 808 !?-30? I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL �� insure or a certificate of Work r Compensation Insurance,or 1 U a eeltinid coon t ehreot(Yi,:cc- 3800 ub 4 } COUNTY OF LOS ANGE FS^' BUILDING AND SAFETY Policy N�"°�..`t'e `_'�`.Z31fl Yi.�r1} .•y .e.- --+�__" - -- ('ertl:fied copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA 0121" ! � } " B UILDING STATION DEPTH t'erti€Ted copy is filed with tire county building Fa Recton ADDRESS UPPER cpartm ALPYY . MANHOLE REFERENCE LOWER tit Appliaa4 � REST TYPE OF CONNECTION LENGTH FROM CROSS ST. _: pf� `' _..d-��—=-._�-.._,__._-_.,�. V' CURB P.L.. M.L. TO P.L. C ,€Lfkh'IC.'ATE OF EXETM ZION FROM A, -',RS' - -- -�—_— -- COMPENSATION INSUPA:NCI; r P.C. Noo^7771 � y C.O. IMP, N7. j0 NO. ('This section need not becompleted iff the Work involved ADDRESS J�' (` d_ � ,' t, _.s'l _)' TRUNK PERMIT NO. ROAD PERMIT NO. by tI9U' permit is for 41t4t': hundred dollars ($100) or It,fs.) ac=r i.DnvF- ---- ASE"1"T 1e 11u. INSTR.No. Dare CITY � V 1 ' TEL. N9�. E I certify that in the pesiarrrtanee of t6r":wryl•k for wlrofich this I„Er;� Permit is issued' I shall not employ any person in any manner DESCRWTKON LOT NO. HWY. OR ST, WIDENING ,so as to bocome ),.bj ct to the Workers' C'ompensatis Laws. _-- n t BLOCK TRACY STAM ENCROACHMENT Date it 'kpplieant-_- '*: ,. - — — NO OF BL.OGS. PERMIT NO, S I'E E:OF LOT NOY' ON LOT NOTICE` i3 APPLICANT: �If, after making 'this Cer:ificate isf -- —slluse, OF — -- I3: e:xteftaonyou, you become Subject to the 4"✓ rkers'' CHARGESBUILDINGS' _ Con'loarlsatia3r provisions of the Labor Code, you must forth- with comply with such provisions or this pepnit Shall be —�--- �� CONNECTION CHARGE FEE CONTRACTORdeemed revoked. _ r t- REIMBURSEMENT FEE LICUNSED CONTRACTORS DFICL,_ARATION ADDRESS I hereby affirm that lam licensed under provisions of Chapter rt` (/ � � .� .1ST—T N?. Gr our �AF PRoc SED sv clYri 1'C�f'S:.F,ts+.. TCL.. Na. .. } %J 4• tti' 9 (cosnrnencing with Section 7000) of Division 3 of the Busi:- � STATE LIC. ness .and Professions Code, and my license is in Cull force and LICENSE NO CLASS effect. -..� -- r. NO CiE5 RIPTION OF WORK K-e � �._ H©I s€ Ewag� coNN cTlN To ti FINAL VALIDATION �t Ircellsc niumber -'-'__: 'Lic.Claw r� �_ UCLF ssWEn_ _ _ kI P VATE 4 EPT, PAN 4i,,SEEPAG , PIT L9R FP _ PITS AND/VR DR INFIELD. Cortit actce_ �s Date�_. If _.— FIrrAL HOUSE SK"LZ CONNECTING TU BY r;,I PITFV.A T.0!]�I£P09AL S STLM. .__. Ilr�.dl' I aero. exempt from the licensnrig, requirements as I am a —�CtTNNI:..CT ADDITION—OLD G,ON licensed architect or a registered profes3ional engineer WORK TO HGE,EF.=a<,­ acting in r2y professional capacity (Section 7051, Bus- Q ERF of s,;�wn�c PTT,aRAI VPrE-.Q` mess and Professions Code), r_xTN.,CrssPOOr DR%' E_L ,MAWHOL. A LTFR, REPAIR OR AS NOON HOUSE SEWER OR.ell".SAL 5Y.STEM Lic.'or Reg.Pio. _ Date — HOME,OWNER-BUILDF.'R DECLARATION I herebyaffirm that I ant exempt from the Contractor's OWN. i Permit LicenseLaw for the following reason (Section. 7031,5, Busi- AUTHORIZATI®N TOTALFEE n<ess and Professions Code): F HAVE_ AT THIS DATE, A CONTRACT WITH —HEREIN NAME coN- -o'l.CTe"R TO CON TCT THEb .AOOVE DESCRI.1? 1—Jif?,T'TIB'd<'r DWE6P,i M1➢G I. as owner of the property, will do Vic work and the Tel TH[. I"DUG SEWIrR. structure is not intended of offered for sale (Section slC;NI-,D T H I c;A of is ,044, Business and Professions Code)., .11. ..oa -- - -- --" OWNERS AGENT '- CONS rRUC rft3'N LENDING AGENCYAaDRE 1 fieri o-y a€firm that t4 ere is a cottstrua tion lending agency — - - - - --for the pe-ff rrmancc of the work for which this permit is tryue£J.(Se,,,!. R,,97,CivC:.). Lender'; _— I_ender's i certify that I have read this application and state that the above.in`ot'mation it correct.I agree to comply with all County ordinances and State laws regi. ating Plumbing and Sewers, artcl heieby authorize representatives of this County to enter upon the above-mentioned property for in,-pecsiorn purpa :zs _.F SEE ICi•:VERSl ISOk I'3(f.'LANA.T09 s° LANGUAGE R ��Siratumof PerX.t° _ Date WORK RS'COMPENSATION DECLARATION 76A6421) APPLICATION FOR PERMIT ., CE. SGS (2-80) I hereby affirm that I have a certificate of consent to se f SEWER-SEWAGE DISPOSAL insure, or a certificate of W(,rkers'Compensation insurance,or a certh"�tieid rape there f (pec.3s0o b C.a COUNTY OF LOST ANGEL�� � d BUILDING AND SAFETY i=OFA APPLICANT TO FILL IN CONNECTION DATA El Certified copy is hereby furnished. j BUILDING .� - ! - STATION DEPTH FIi Certified copy is filed with this county building ui�p(ction ADORess �/ � UPPER department MANHOLE REFERENCE 'A�I �.: Y LOCALITYct; i� ` � 7 �>z6.� e �1..c' LOWER NEAREST OF CONNECTION LENGTH FROM CERTIFICATEOP I:XEvIP'1ION I'RD I WOI2KI:R cRoss s'r_ tl i "C =--- v, cuRB__ P.L. M.L. TOP L. __'--- P.C. COMII•',tvS,�TION INSURANCEC oWNc,R � -0f , CO. IMP_ NO. aoe (This section need not be completed if the work involved MAIL _ ? ,pI ADDRESS ^?- f, � i�,Q,: (,��y: TRUNK PERMIT NO. ROAD PERMIT NO. by the permit is for one hundred doll`arj (5100) or less.) FIDAViT I WAIVER EASEMENT RECORD. INSTR. NO. DATE CITY" TEL. I certify that in the performance of the work for which this LEGAL permit is issued:, I shall not employ any person in any manner DESCRIPTION LOT NO. HWv, OR ST. WIDENING so as To becurne sert tc. the Workers' Compensation Laws. — l�t_i � F BLOCK TRACT STA.,E ENCROACHMENT Dat'A /I Applicant y NO. OF eLDGs. — PERMIT NO. No, ---- SIZE OF' LOT NOW ON LOT CU.) NOT, 'Z'-O .API'LICAN'T: If, after making this Ce.frficate of -- 0. Exemption, you should become subject to theWorkers' USE OF CHARGES u9 BUILDINGS Compensation provisions of the Labor Code, you must forth- with comply with such prcMsions Or This permit .shall be CONTRACTOR CONNECTION CHARGE FEE deemed revoked � -� - REIMBURSEMENT FEE LICENSED CONTRACTORS D C'I ARATXON ADDRESS ` I heteby affirm that. I am licensed under previsions of Chapter i t i C f -7 DISTRICT NO. GROUP MAP PPR OC�°JS EP BY CITY �. I `Ui,:tr V� TEL. bd0. G(; rY �" ti BK n rf/ 9 (commencing with Section 7004)) of, Division 3 of tllc I3'iyci- r'�'-� �� y STATE LIC. Hess and Professions Code,alai my license is in full force and -fi t LICENSE N(5 C CLASS - effect. NO.!! DESCRIPTION OF WORK FEE r�y ` i � C.7 HOUSE SEWER CONNECTING TO y FINAL VALIDATION License Number_ 7_�r Lic. Class ��� PUBLIC SEWER : nA r SEPTIC TANK,SEEPAGE PIT OR PDate PITS AND gR ORAINFIELO F.NAL. f. HOUSE SEWER CONNECTING SIYTO IV PRATE DISPOSAL 'ISi'EM — BY I am exempt froxxl tiae licensing requirements a5 I an) a CONNF_CT AODtT1ONAL BLDG,OR licensed architect or a registered professional engineer WORK Th. HavSE.GEW R acting in my professional capacity (Section 7051, Bus- ov'eRELDwr EEPe E PIT,DRAINFTELP �— iness and 1rD fe55i pHs Lode). EXrN. C.c.S5POOL,ORYth'ELL,MANHO E ALTER.,REPAIR OR ABANDON HOi SE SEWER OR DISPOSAL SYSTEM Lic.or Reg. BONE OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNERS Permit _ S ��Cf License Law for the following reason (Section 1031.5, Pusi- AUTHORIZATION TOTAL FEE ness and.Professions Code): I HAVE.' AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I, as owner of the property, Will do the work and the TO THF PUBLIC SEWER. structure is not intended or offered for sale (Section SIGNED THIS DAY OF—­-119— ,044, ya= __ t9_,044, Business and professions Code), OWNER OR OWNER',e AC,ENT CONSTRUCTION I IM)ING AC ENCY — --- — � I hereby afflrni That mere is a construction lending, agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). I.,endei's Lender's Address-- I ddress -I certify that I have read this applicAior :.incl siate that the above information is,correl i. I agree to comply with all C.oul:ty ordinances and State laws regulating' Plurabing and Sewers, and hereby authorize representatives of this County to enter upon the abovlr-ene;iitloned property for inspection purposes. '5 SET RF;4 IRSE FOR?:'x_I'LA ATOR.Y LANG=LAGk_: ign t r of Permi ,� e , { Date y