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HomeMy Public PortalAbout5416 A & B MCCULLOCH AVE_Sewer__ WORK E kS'C+JMPENSA"I ION DECI:r'1FtA'IION' CE 848(2-80) APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent w self SEWER•-SEW` E DISPOSAL i Insure, or a certificate,of Workers'Cornlermition Insurance,or a certifie tijp p v th:feaf-Sec. 3800, b ! COUNTY OF LOS ANGELS + BUILDING AND SAFETY"" Policy I�°'Si'.�tti`�� t'f' �ornpan y���w:-.,�_����, (�� / FOR APPLICANT TO FILL IN CONNECTION DATA Certified ropy is hereby furrushed. -------� Gut DING � '+ STAT!�,N DEPTH ® Certified copy is filed with thecounty building inspection UPPER HLocaLerY L — y Iapa lrLnf• �} ( � MANH Le REFERENCE LOWER Date ! / Applicant-(_-1 NEAREsr la a CONNECTION ocoEerroN LENGTH FROM - CROSS ST _,j 1, „✓� Y. CURB P.L. M.L. TO P,L. CI RTIC IC:ATE OF EXEMPTION FROM WORKERS' ---. _ COMPENSATION INSURANCE s P.C. NO. OWNER6 ,� ,. CO. ITS P. NO. JOB NO. MAIL �iy'`�,j •r - // •`l- (Tt71a3 �'e#>LtPUtI 11eS',d Xtt7t tAt: etarnptetecl lt' file SWOr/I1C i11VC11t%L^d- pDREsS �7., _� � TRUNK: PERMIT NO. ROAD PERMIT NO. by the permit is for one hundred dollars ($10J) or less.) ff G.64+ of »� AFFIDAVIT WAIVER EASEMENT RECORD. INST R. O. GATE Y l•1 f. [l S .CITY '`_ I TEL. NO. � "•.' fq I certify that In the performance of the work for which this LEGAL permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. � HWY. OR ST. WIDENING so as to c In subject tis the ✓va rtccrti C'esrnpensatton I.ativ . ---- - — L) r BLOCK TRACT STATE: ENCROACHMENT Applicant_ _ ,� �' �— PERMIT NO. a- - _ 4:-- NO, OF BLDGS. (n NCiTICE O APPLICANT: It, after malting this C rP.ificate of suzE OF Lor No6u oN Lor z Exemption, you should become subject to the %Yorkers' USE OF - BUILDINGS CHARGES' Comp:nsation provisions of the Labor Code, you must forth- _ with comply with such p j� �-- - coNvs.crloN CHARGE FEE p y provisions or this permit shall he CONTRACTOR Jti,4 P deemed revoked. i{ _> _ __J,;s,., -- r -). — REIMBURSEMENT FEE mSTiD CONTRACTORS DECLARATION ADDREss ln� h' ,a a �� I j+'q{ �,k._-�, 1 ❑3-STRICT NO. [.:ROUP MAP PR Cr D BY I hereby affirm that I arra licensed under provisions of Chapter b t I .r CITY ,j% t"1$i L.-L.J TEL. NO. 'k- �`�l v'Sy,, 3' -yv elc PG ..�'"' 9 (commencing with Section 7000) of Division of the Busi- l L- eel STATE. LIC. s•'q -� ncss and Professions Code, arid my license as in full force and LICENSE NO. CLASS effect. -. -6 F10. DESC FYdPTIDN OF WORK P'6E VALIDATION(�� .M1'� -. ✓� ., 1 HOUSE SEWER CONNECTING TO FIP1/aL ALIDA ION License Number Lie.Class—,—( �— FUH4.iC SEWC.R — OAT- SEPTIC TANK,SEEPAGE PIT OR PITS AND/GR DRAINFiELD Con+',+I'l3ctorT,.-} ',a, �ate - ------ FINAL 41 HC•USE SEWER CONNECTING TO _ PRIVATE DISPOSAL SYSTEMBY _ — ► —`�— I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG. QR J icensed architect or a registered professional engineer WORK TO HOUSE SEWER acting. In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DR AIN P'IE LD mL S and Professions Code). E%TN.,CESSPOOL,DRYWELL,NIANHOLE ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic,or Reg.Iia._-- _ Date_ — - HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OyrNEp'SPermit s '' License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE ` 0 ness and Professions Code): 1 HAVE AT THIS [TATE A CONTRACT WITH THE. HEREIN NAMED CON- 5'RAE',TOR a0 CONNECT Y'FeE-VE DES,Rb.ED FXISTING DYIELLING I, as owner of the property, will do the Work and the TO THE PUBLIC SEWER. structure is not intended or offered for sale (.lection SIGNED THIS DAY SOF 19 7044, Business and Professions Code). OWNER OR — OWNERS AGENT CONSTRUCTION LENDING AGENCY ADDRr_s5 — —~---�-- I hereby affirm that there is a construction lending agencyfor the; performance of the work for which this permit is issued(Se,:. 3097,Civ-C.). Lender's Names Lender's Address I certify that I have read this application and ,state that the above information is correct. I agree to comply with Tall County o-rdinances and State laws regulating Plumbing and Sewers, and herebyauthorize representatives of this County to enter upon the above-mentioned p fopertp for inspection.purposes. ..' Q SEF REVERSE; FOR EXPLANATORY LANCiL, Stgnat nf`Permiftse '{ t Date 0 P Ve OR KERS'COMPENSATION Dr CLARA f loN - 36A6420 APPLICATION FOR PERMIT I hcrehY affirm that I have a certificate of consent to self CE 808 (2 Ps©) S E E R-S E tl Y' EDISPOSAL insure or a certificate of Workers'Couil cni,ation Insuran%e,or T a certili d co}f vthere of Sec.. 380( h f. J t COUNTY OF LOS ANGEL S tBUILDING AND SAFETY (a t ) - Pe lie} No; V) Cain any �L Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA SUiLDIN"I 'J STATION DEPTH ADDRESS El UPPER Certified copy is filed with the county building inspPCiil)n ----E: � �y— MANHOLE RE.�ERENc LoevF.sx department, 1/.� - LOCALPr � !� Date _. A l.s 2. d -- -- — Applicant -= � �Y -- NEAREST TYPE OF CONNECTION LENGTH FROM CL OF I=?tEMYI'ItJN FROM WORKERS' E.Ross ST. v. culls P.1. M.L. To P.L. -- _ t .--- — —.. —. COMPENSATION INSURANCE (, � P.C, No. OWNER ._ Co. Yelp. NO. JOB NO. ,�"..._ •••• MAIL } `This section need not he completed if the work involved ADOR Ess � �-- � �-q,,,;;/1 TRUNK PERMIT NO. ROAD PERMIT NO. >- by the permit is for one hundred dollars ($lop) or less.) !NST..NO. AT C TY eiA APT. � 0 1 certify that in the performance of the work for which this LEGAL permit is issued,.I shall not employ any person in any manner D'ESCRIPTiON LOT NO. ,. HWY, OR ST. WIDENING o .is to beCo rte stabje t to the Worke s (.ompcnsati,En Laws. -- O -!! BLOCK TRACT * STATE ENCROACHMENT DateI, / PE NO. (� Applicantr- :LIU, _. NO. OF GLDGS. 1L1 NO]yil.��/O APPLIC ANT: If, after anaf-rng this C>ertificate of slzE o� Lor NOW ON LOT � Exemption, you shou)d become suh�ect to the Workers' USE OF' CHARGES Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit sha)l beCONTRACTOR � i .l, � � '� CONNECTION CHARGE FEE deemed revoked- 4 Y `a•' ! 1'. 1 7J l REIMBURSEMENT FEE: LICENSED CONTRACTORS DECLARATION ADDRk,sf#� I hereby affirm that I am licensed under provisions of Chapter �i•' f p olsrRlcT NO. GROUP MwP PROF ED®Y r CITY /L dk,- �+i�� r TEL. NO. �_.-'t R t '!a ..j •-' ex ,�� M 9 (r:ommencing with Section 7000) of Division 3 of the Busi- 7 r�' ness and Profes,4ons Code, and my license is in full force and STATE LItlC. CENSE NO. effect. NO DESCRIPTION OF WORK FEE 1 �* HOUSE SEWER CONNECTING: To FIN°J J � � VALIDATION License Number�✓= �.,Lie. Class— ! I ,1U®Llc SEWER — 0DaY'i f gr 1 SEPTIC TANK,SC-PAGE PIT OR £ a 1PITS ANDfOR DRRINp1EL 5 A FINAL f l H.Ou sE SEWeR CONNECTING TO BY •=4n'§,.-. P... TE DISPOSAL SYSTEM T am exempt from the licensing requirements as I am a CONNECT ADDITIONAL @LOG.OR licensed architect or a registered professional engineer WORK TO HOUSE SEWER _ acting in my professional capacity (Section /051, Bus- 01/ERF=LOW SEEPAGE Pi T,DRAINFIELB iness and Professions Code). EXTN•,CESSPOOL,ORYWELL,MANHOLF-' Code). I ALTER, REPAIR OR 0.01.111N H1151 SEWIER OR DISPOSAL SY 5'YEM Lie.or Reg.No- Date_ HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNERS Permitf ) License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION I TOTAL FEE 1 ness and Professions Code): I NAVE A'F THIS DATE A may. - WITH THE H NAMED CN CRACTOR YO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING r� J' 1, as owner of the property, will do the worst and the TO THE PUBLIC SEWER. structure is not intended or offered for sale (Section SIGNED THIS Dam or' 19 7044, Business and Professions Code). OWNER OR OWNER.AGENT CONSTRUCTION LENDIiNG AGENCY ADDRESS_ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ. Lender's Name Lender's Address I certify that I have read this 2pplication 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. SEE REVERSE FOR EXPLANATORY LANGUAGE; i nafu, cyf Permltfee /1 Date Cy i 1 I ..,.-i r��., ���'t / S