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Home My Public Portal About6211 MUSCATEL AVE_Sewer__ WORKERS' COMPENSATION DEC!ARATION I hereby,iffirm that I have a ce tlficaie of consent to self ?x0051 DPW 6,' 9 m4e, ora ernftcote of Workers'Compensation Insurance, or aha a20 a ce,t,fi,d py thereof (Sec. 3800, Lab APPLICATION FOR PERMIT = r Pol)cy Nb S_ X Compony..._ �r r ✓ �x_z. p L,_j Certified copy Is hereby furnished. P SEWER - SEWAGE DISPOSAL i.'}" eriified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportmer. Date _ _. erAppII, FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' Buu.r,INr., �5 COMPENSATION INSURANCE ADDRESS �'rT'r7� &.,L'c.'_ �'. STn.,N DEPTH (This section need not be Completed If the work involved by the � VANHOLE PTFERENCE UPPER permit is for one hundred dollars ($100)or less L.GGAUTY' *_may _ ,',_ LOWER NEAREST r{PE OF CONNECT,6N LENGTH FROM i certify that in the Performance of the work for which this CROSS ST. r ur,B p M TOPL permit is issued, I shall not employ any person in any manner LEGAL NO So as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO 'CO :MP NG JOB NO Date Applicant—. BLOCK TRACT PUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT If, after making this Certificate of AS' 'OH C RA / AFF;DAwr wnlvea EASEMENT RECORD Insta NO DATE g ivtAp f30GK PAGE fiCEt.Ci"� Exemption, you should become subject to the Workers' NO OFBLOGS Compensation provisions of the Labor code, you must forthwith SSE OF LOT N W ON L 0 F HWr CAST WIDENING comply with such provisions or this permit shall be deemed JSE OF revoked, BU1LOINGS STATE ENCROACHMENT ar'y y LICENSED CONTRACTORS DECLARATION PERMIT NO OWNER. N t.'.'. I hereby affirm that I am licensed under provisions of Chapter 9 (Commencing with Section 7DDO) of Division 3 of the Bust- MAIL .ADDRESS CHARGES ness and Professions Code, and my license is in full force and effect. CITY 7 F_L.NO OtdN€CTION CHARGE FEE License Number 52 ce ,maJc_6 1.1c Class ilf"-V' of^B' CONTRACTOR �� - ICT I4tF.N7 FEE 7✓ ,� �"f . CaniroCiar �a DI rR!Ci rdL) GROUP MAP ,PRc?(E55tiD Bv' C..�! vatP. .�,2_ ADDRESS / C'g.�{�r-4 5K PG '�., ❑ I am exempt under Sec _ of the L.A.Co. y l .) f d CITY -L ct J<'s� /!r?" C}S d L ° rf` O Plumbing Code and.or Sec._ of the STATE LC. F NAI. U LICENSE NO. : i.5^C.? 'LASS � �. ATE VALIDATION z B. & P. Code for the following reason_ tyO. aEscatPnoNofwoRK c3 FEE rp CF H SE ANLR CINNE. .NG.0 FINAL - Date PLBEi SEVER By W SEPTIC TANK SEEPAGE PIT OR Signature S AIND OP DRAINF ELD OWNER-BUILDER DECLARATIONE SENFR CO aNECt ' "' Z _PRIVTE DIS OSAI SYSTEM I hereby affirm that I am exempt from the Controctor's license CONNECT ADDIT ONAL BLDG OR :j•%f i> k }c" Law for the following reason (Sector. 7031.5, Buisness and Pro- WORK TC -.o ,r SEWER �s .c. :.. Jt RF.IC SEEPAGE .AM1FEtD CESfe55fOnS Cade EXTN 'POOLDRvE N1ANHOL,E I, as owner of theproperty, or m em to ees with wages as A R. REPAIR OR ABa Ho. E Y P Y 9 SEWER OR DISPOSAL Sv EM '„ their sole compensation, will do the work and the structure TOTAL -�--.+'m'"4 x (1110 Is not intended or offered for sole (Section 7044, Business r-.. 41-71 fad, and Professions Codel. ---- I'II I,as owner of the ra ert am exclusive) controctrng with C AA t°'L..r P- Y. Y OWNER'SPE?rmif $ 7i n,.licensed cantroetors to construct the project (Settlor 7044,Business and Professions Code). AUTHORIZATION TOTAL FEECONSTRUCTION LENDING AGENCY I HAVE AT THiE DATE A CONTPZC1 v rH HE HEREN NAVE i�� y ��F1NNE CT T,IE ARO'A JE SCR BE X:ST N( ,.AEL'. "HE'P_F 0000 0t0ihereby affirm shot there is o cons*ruction lending agency for the performance of the work, for which th;s permit Is ,r + 1,325 1 Ptr ;s'5 issued (Seca 3097, Civ. C ) SIaNEt nii� F t✓ paY OF OWNER OP - Lender's Name _-------------'-- Ov.NER -t Lender's Address,___.________ _ I certify that I have read this application and crate that the above information is correct. I agree to comply with all County ordinances and State laws regularinq Plombing and Sewers, and hereby authorize representatives of this Cavnty to enter upon thole-coned property for inspection purposes grata e am ee D re 4 SEE REVERSE FOR EXPLANATORY LANGUAGE y C WORKERS' COMPENSATION DECLARATION 1•hereby.4ffirm that 1 have a certific9te of consent to self 20-W51DPvv6/89 L insure, or n certificate of Workers' Compensation Insurance, or 'it5Afi42D a certified cagy thereof ,Ser._ 3y Laq C APPLICATION FOR PERMIT Policy No-------,Company E i Certifled cagy is hereby furnished. SEWER - SEWAGE DISPOSAL `L_1 Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deport Date—( '` � -Applicant-- �,-�� FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE TOR,G INSURANCE L, STnTICN DEPTH jhis section need not be completed if the work involved by the vnn,wu UPPER permit permit is for one hundred dollars ($100)or less._! LOCAI'TY tuwER NEAREST Y.E i-�F C;C'sNECTION ;,TNGTH FROM I certify that in the performance of the work for which this cROS.sT. v CEJRB P L nn L TQ P t permit is issued, 1 shall not employ any person in any manner LEGAL, PC No so as to become subject to the Workers' Cara pensation Laws. DEPCR!PnON Lai NO. CO .MP NC J08 NO, 3LOCK TfgACq TRUNK PERMIT NO ROAD PERMIT NO Date__—___Appl/cont-,— NOTICE TO APPLICANT: If, after making this Certificate of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSiR NG PATE g MAC BOOK PAGE E'ARC€I. Exemption, you should become subject to the Workers' NO,OF d D'i35. Compensation provisions of the labor code, you mist forthwith SIZE OF 1-07 Nalti'.QN LOT HW` OR ST W DENintC, comply with such provisions or this permit shall be deemed USE OF revoked. BUILDINGS STATE ENCROAC HAAENT LICENSED CONTRACTORS DECLARATION PERMIT NO I hereby affirm that i am licensed under provisions of Chapter OWNER 9 (commencing with Section 70001 of Division 3 of the Busi- MAILADDqESS CHARGES ness and Professions Code, and mV license is in full force and effect.� �t�s :rry L wi�- CON v.<:T ON CHAR €FEE License Number.` k- a_/bc. Class_-- /M� y,,, /. REIMB..iRSc'JiE NT FfF 777--- ��,/ {p,�• i�N'riAC rORr-�'�A ,.�/1 �•J Contract ar j, � j_•Date_ "� ""'" r -' DI STRICi'Jf5 ORC7UP MAP P,?,(,7� 5Et3 Bir ADURe:S :�zl(2Es PG ❑ I am exempt under Sec __ of the L.A.Ca. / {�,+\ a E2 V O Plumbing Code and/or Sec. _of rhe ST ATE rl `TENSN �r VALIDAfION z B. & P. Code for the following reason. r�NOT _ DESCRIPTION OF WORN FEE HOUSE 5E a ^iz��r-r-..I a;ro F!NAe Date PUBLIC S.1"R ) SEP11C ANK EF SCE PIT CIR BY '��'C� A LU Signature — PIT. AND OR DRA NFIE{D _ ^s t0 a^n G F OWNERBUILDERDECLARATION HOUSE EWER )N E II ar ,a r•_ .•.,` PRIVATE a SPOSA,SY57EM _ I hereby affirm that I am exempt from the Contractors License CNNECT A n_IoNA: BLDG OR ► T T EINC Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HO i,€SEWER OVERFLOW 5EEPAGE PIT DRAINF�E.D '� t!F:" "�- 4ession.s Code): EXTN Crs Pr,r,L DRIV Eu,MANHOLE IffAL 1, as owner of theproperty,or m' ern la'ees with wages a5 ALTER REPA R OR ABANDON HOUSE d- F^, r•.. S { g SEWER i-jR D ISPOSAi,SYSTEM CHECK £3. -E Their sole compensation, will dei the work and the structure -- — "'s is not intended or offered for sale (Section 7044, Business _ i.FANGE a; # and Professions Codey --- - 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, OWNER'S Permit Busmess and Professions Codel. AUTHORIZATION TOTAL FEE Q ; CONSTRUCTION LENDING AGENCY HA E AT THIE .A 7 A -0147RArT WITH iIE HERE NAMEa?RA oR T-`> :t Yi Arl114- , I hereby affirm that there is a construction lending agency - COtUNECT THE,4P TSE JtSCR PFD E.x15Tv _WELtINO ,I THE aIIB. -SEWERPilo for the performance of the work for which this permit Is _— issued (Sec 3097, Civ. C.i. S C:NF.h THiSA DAY OF. _19_ Lender's Name._.._ - C3:N'NERS AGENT AD",KESS Lender's Address_ ___ I certify that I have read this application and state that the above Information 1s 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 abov mentioned property for in,pection purposes. S gn tune of Permittee Date SFE REVERSE FOR EXPLANATORY LANGUAGE