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Home My Public Portal About5304 NOEL DR_Sewer_7/3/1985_ WORKERS COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self 7 11 M or a certificate of Worke pe n Insurance bAcn2D U fi V th a CEW8(REV 1/83) APPLICATION FOR PERMIT rtified copy Is hereby furnished SEWER - SEWAGE DISPOSAL Certs led py is filed with t e dbnty b Ing Insp I n COUNTY OF LOS ANGELES BUILDING AND SAFETY rime Da App Ic FOR APPLICANT TO FILL IN CONNECTION DATA RTIFICATE OF XEMPTION FROM WORKERS BUILDING �"� COMPENSATION INSURANCE ADDRESS v r STATION DEPTH (This section need not be completed if the work Involved by the LOCALITY MANHOLE REFERENCE UPPER P ER permit is for one hundred dollars ($100)or less ) I certifythat in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM P CRO5S Y CURB P L ML TOP t permit is Issued I shall not employ any person In any manner so as to become subject to the Workers Compensation Laws P C NO I P OWNER CO IMP NO JOB NO Date Applicant AD &Sa TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT If after making this Certificate ofCI TE O r AFFIDAV WAIVER EASEMENT RECORD INSTR NO DATE 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 L/ LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NO SIZE OF L NOW ON LOT 1 hereby affirm that I am licensed under provisions of Chapter USE OF 1 i 9 (commencing with Section 7000) of Division 3 of the Busl BUIL CHARGES ness and Professions Code and my license is in full force and effect /rmay/ ` / CONTRA OR C NECTION CHARGE FEE `� ` UyTDei c C I a Y ADD RE EIMBURSEMENT FEE Contr • ZZ p �� DISTRICT NO GROUP MAP PROCESSED BY O L NO SK PG CATE I am exempt under Sec o he L A Co ENSE N ci 5.V Y63 OL Q Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL _ VALIDATI PUBLIC SEWER HOUSE SEWER CONNECTING TO DATE B 6 P Code fort following reason SEPTIC TANK SEEPAGE PIT OR d PITS AND/OR DRAINFIELD FINAL y Date HOUSE SEWER CONNECTING TO BY Z PRIVATE DISPOSAL SYSTEM Slgnatur CONNECT ADDITIONAL BLDG OR ► BUILDE RATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT DRAINFIELD I hereby a Irm that I am ex pt from the Contractors License EXTN CESSPOOL DRYWELL MANHOLE Law for the following rea n (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE 1237.5A fessions Code) SEWjqOR DISPOSAL SYSTEM El as owner of the property or my employees with wages as # 5 4 their sole compensation, will do the work and the structure I • 1 5 1LO 0 is not intended or offered for sale (Section 7044 Business and Professions Code) OWNER'S Permit $ e - 154,005 ❑ I as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE d licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO O 0,71 -85 Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO TH BLIC SEWER CONSTRUCTION LENDING AGENCY , I hereby affirm that there is a construction lending agency SIGNED THIS Y OF 19_ for the performance of the work for which this permit is OWNER OR issued(Sec 3097 Civ C ] OWNERS AGENT ADDRESS Lender's Name Lender s Address 1 certify that I have read this application and state that the above in rmation Is correct I agree to comply with all County or din es and State laws regulating Plumbing and Sewers an ereb authorize representative t s County enter a ve-mentioned art ori action pu oses Signature of rmittee p6te SEE REVERSE FOR EXPLANATORY LANGUAGE 4, WORKERS COMPENSATION DECLARATION •I he by affirm that I have a certificate of consent to self ensu r a cer Ificate of Workers Compe tion Insurance or 76A642D yt� _th e f c ab CE808(REV 1/831 APPLICATION FOR PERMIT ertlfied copy Is hereby furnished SEWER - SEWAGE DISPOSAL ❑ Certified co y Is fiI d with the y bu ng In ction COUNTY OF LOS ANGELES BUILDING AND SAFETY dep e Dat Appllca FOR APPLICANT TO FIL N CONNECTION DATA RTIFICATE OF EXEMPTION FROM WORKERS BUILDING /� COMPENSATION INSURANCE ADDRE59Cj STATION DEPTH 11 (This section need not be completed if the work involved by the • MANHOLE REFERENCE UPPER permt Is for one hundred dollars($100)or less ) LOCALITY I certifythat the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM in P CRO! ST r Y CURB PL ML TOP L 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 MAO go�A NK PERMIT NO ROAD PERMIT NO Date Applicant AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE NOTICE TO APPLICANT If after making this Certificate of TEL N Exemption you should become subject to the Workers EGAL 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 ENCROA MENT SIZE OF LOT LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NO I hereby affirm that I am licensed under provisions of Chapter USE OF NOW ON LOT L 1�` I 9 (commencing with Section 7000) of Division 3 of the Busi BUILD 5 CHARGES ness and Professions Code and my license is in full force and / effect / CONTRA CONNECTION CHARGE FEE LiCHAffiNb iC CICS ' REIMBURSEMENT FEE � ! !!! SSW Conti, O r v ISTRICT NO GROUP MAP PROCESSED BY 0 TEL ;�^ `, I?� PG ❑ I am exempt under Sec of the L A Co LICENSE TE cc `� •v� ��/ �K 63 OW Plumbing Code and/or Sec of the jNO DESCRIPTI F WORK FEE FINAL ] HOUSE SEWER CONNECTING TO DATE VALID A N B &F Co or the following reason PUBLIC SEWER SEPTIC TANK SEEPAGE PIT OR NAL y PITS AND/OR DRAINFIELD FINAL Z HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM SI CONNECT ADDITIONAL BLDG OR ► OWNER-B DER DECLARA WORK TO HOUSE SEWER I hereby affirm that 1 exempt from the Contractor License E�XTENFLCESSPOOL DR EPAGE PIT YWE RAINFIELD MANHOLE Law for the fall a lowin reason (Secton 7031 5, Buisne and Pro ALTER REPAIR OR ABANDON HOUSE fessions Code) SEWER OR DISPOSAL SYSTEM ;123 7 6 A ❑ 1 as ownerf the property or my employees with wages as their sole compensation will do the work and the structure # • • • • 1 0 Is not intended or offered for sale (Section 7044 Business and Professions Code) OWNER'S Permit $ d ( • • 2 7 5 0 ❑ I as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEONTRACTOR TO • • • 2 7.5 0 5- Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE LIC SEWER CONSTRUCTION LENDING AGENCY00O Q 71 —8 5 1 hereby affirm that there is a construction lending agency SIGNED THIS AY OF 19_ for the performance of the work for which this permit 1s OWNER OR Issued(Sec 3097 Civ C ) OWNERS AGENT ADDRESS Lender s Name Lender s Address / I certify that I have read this application and state that he above formation is correct I agree to comply with all C unty ordl nces and State laws regulating Plu bi and wers a he uthorize represen Ives his ounty a ter e a e-mentioned rt r in cti p p0 s Signature of P mittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE