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Home My Public Portal About5309 NOEL DR_Sewer__ ' — WORKERS COMPENSATION DECLARATION I hewbx offIlm that 1 have a certificate of consent to self Insutle or a cdrtificate of Workers Compensation Insurance or 76A647D 1a certified copy thereof(Sec 3800 Lab C ) CEODS(REV 1/831 APPLICATION FOR PERMIT Policy No��9impany SEWER - SEWAGE DISPOSAL El Certified copy Is hereby furnished ❑ Certified copy Is filed with the unfy building insj ion COUNTY OF LOS ANGELES BUILDING AND SAFETY depart enc Date A0011 ant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXE M N FR M WORKERS BUILDING COMPENSATION INSURANCE ADDRESS N00J bf STATION oElmt (This section need not be completed If the work Involved by the LOCALITY 1 G r � MANHOLE REFERENCE UPPER permit Is for one hundred dollars($100)or less ) LOWER OM 1 certify that in the performance of the work for which this NEAREST T TYPE of CONNECTION ON M L THP L D YG Y CURB PL ML roPl permit is Issued I shall not employ any person In any manner t' PC NO so as to become subject to the Workers Compensation Laws OWNER eve +Nan �lairr CO IMP NO JOB NO MAILl r TRUNK PERMIT NO ROAD PERMIT NO Date Applicant ADDRESS l NOTICE TO APPLICANT If after making this Certificate of Cin L TEL NO R8S g AFFIDAVIT WAIVER EASEMENT RECORD INSTR ro0 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 LICENSED CONTRACTORS DECLARATION NO OF OT PERMIT NO L I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT 9 (commencing with Section 7000) of Division 3 of the Busi USE � 04ARGES ness and Professions Code and my license Is In full force and effect CONTRACTOR CONNECTION CHARGE FEE License Number LIC CIOSS ADDRESS e q S REIMBURSEMENT FEE '. DISTRICT NO GROUP MAP PROCESSED BY O. Contractor Date STAT TEL NO /J BK PG ElV STATE LIC ((/ I am exempt under Sec of the L A Co LICENSE rip 2-OS—! cLAss � Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL r O HOUSE SEWER CONNECTING TO DATE VALIDATI N PUBLIC SEWER B 8 P Code for the following reason tri 5EPrIC TANK SEEPAGE PIT OR O. IN PITS AND/OR DRAINFIELD FN Date HOUSE SEWER CONNECTING TO ZI_400' 11P BY PRIVATE DISPOSAL SYS Signature CONNECT ADDITIONAL BLDG OR OWNER BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractors License �NFLCESSPPOOLLDDR IYWELL MANHOLE Law for the following reason(Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE fesslons Code) SEWER OR DISPOSAL SYSTEM ❑ 1 as owner of the property or my employees with wages as their sole compensation will do the work and the structure is not intended or offered for sale (Section 7044 Business and Professions Code) I OWNER S Permit $ 3 I as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEEt licensed contractor to construct the protect (Section 7044 I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO §3768A 4" Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER // e e e e 10 1 CONSTRUCTION LENDING AGENCY op M wl 1 hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19 1 * ,, 2150 for the performance of the work for which this permit Is OWNER OR I issued(Sec 3097 civ C) OWNERS AGEO ! I e e 021505 Lender s Name ADDRESS 01 07-86 Lender s Address 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 jaws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter upon the above mentioned property for Inspection purposes vl/ • 74 7, Signature of P itfee DaIV SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self Insure or a certificate of Workers Compensation Insurance or 76A°°zD a certified copy thereof(Sec 3800 Lab C ) CE WS(REV 8/81) APPLICATION FOR PERMIT Poll No Company ®s Cert%FICATE reby f Wished SEWER - SEWAGE DISPOSAL ❑ Certed w county building Inspection I COUNTY O LOS ANGELES BUILDING AND SAFETY dep Datepl a FOR APPLIC O FI IN CONNECTION DATA EXEMPTION FROM WORKERS BUILDINGENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed if the work Involved by the LOCALITY MANHOLE REFERENCE X34:0R permit is for one hundred dollars($100)or less ) NEAREST OF CONNECILW I certify that in the performance of the work for which this ST TYPEI LENGTH FROM Y B PL MI Ml TOPL permit is Issued I shall not employ any person in any manner PC NO so as to be me 8 ject to the Workers Compensation Laws OWNER CO IMP NO Joe NO V MAIL D PERMIT NO � Dote pp Icons ADDRESS AFFIDAVIT WAI R EASEMENT RECORD INSTR NO DA O NOT E TO PLICANT If after making this Certificate of CITY L NO V Exemption you should become subject to the Workers LEGAL U Compensation provisions of the Labor code you must forthwith DESCRIPTION LOT NO HWY OR ST WIDENING IL comply with such provisions or this permit shall be deemed / H revoked BLOCK TRACT STATE ENCROACHMENT Z LICENSED CONTRACTORS DECLARATION No OF B PERMIT NO SIZE OF LOT NOW O LOT I hereby affirm that I am licensed under provisions of Chapter ISEOF 9 (commencing with Section 7000) of Division 3 of the BUST BUILDINGS • CHARGES ness and Professions Code and my Iicens in till for an effect CONTRACTOR CONNECTION CHARGE FEE License Nu LIC ClasB T ADDRESS • REIMBURSEMENT FEE Contract Date DISTRICT NO GROUP MAP PROCESSED BY CITY NO BK PG ❑ I am exempt under Sec of the L A Co ICE E ISENOJOW LIC Plumbing Code and/or Sec of the N01 DESCRIPTION OF WORK FEE AL HOUSE SEWER CONNECTING TO �/ DATE ALIDATION B 8 P Code for the following reason PUBLIC SEWER SEPTIC TANK SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date NATE DISPOSAL SYS ING TO BY \i Signature CONNECT ADDITIONAL BLDG OR V OWNER BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT DRAINFIELD 1 I hereby affirm that I am exempt from the Contractors License EXTN CESSPOOL DRYWELL MANHOLE Law for the following reason (Section 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE ' fessions Code) SEWER OR DISPOSAL SYSTEM L 9 9 7 3 2 A ❑ I as owner of the property or my employees with wages as ' # ° • • • 1 0 their sole compensation will do the work and the structure is not intended or offered for sale (Section 7044 Business Permit 2 — 2750 and Professions Code) OWNER S j; ❑ 1 as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE •yo 0 2 7 5 licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH TH HEREIN CO R R TO i Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING LING TO E R 0 2 1 1 —8 3 CONSTRUCTION LENDING AGENCYSIGNED THIS pop hereby affirm that there is a construction lending agency 19_ for the performance of the work for which this permit is OWNER OR Issued (Sec 3097 Civ C ) OWNERS AGE ADDRESS • ° Lender s Name Lender s Address- / I certify that I bdie read this application and ate that the abovAinformis corre mply ith all County ordine laws regul Ing P b g and Sewers and ze represent Iv h County to enter uponntioned or ectl urposes ign are of Permit a to SEE REVERSE FOR EXPLANATORY LANGUAGE