The URL can be used to link to this page

Home My Public Portal About6412 OAK AVE_Sewer__ WORKERS'COMPENSATION DECLARATION �% ��%1 / J/ I hereby afftirm that I have a certificate of,consent to self a orY*certificate of Vyorkers'Compensation Insurance, or 76A642D ce'rrifled*co they of Sec. 3800, cEaoBIREv lies; f'Ulicy Nc! -P ✓! Company ' � � APPLICATION FOR PERMIT ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL :Ej Certified copy is filed with the county building sfi pection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment. yi _ l Date�-� 1 Applicant � /�r r' � FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING p i h, J STATION DEPTH COMPENSATION INSURANCE ADDRESS J ' UPPER (This section need not be completed if the work involved by the LOCALITY -7-17,4 I '' /' MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or less.) I certify that in the performance of the work for which this CROSSSY ST. TYPE OF CONNECTION LENGTH FROM permit is issued, I shall not employ any person in any manner + CURB P.I. M.L.TO P.L. so as to become subject to the Workers'Compensation Laws. OWNER /t y, X � , � JOB NO. V y�� CO.IMP.NO, LOB NO. MAIL -TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS AFFIDAVIT I WAIVER EASEMENT I RECORD.INSTR NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL NO. 1 2 j' 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 r comply with such provisions or this permit shall be deemed '- revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO OF BLDG5 FERMI.NO. SIZE OF LOT NOW ON LOT ! I hereby affirm that I am licensed under provisions of Chapter to �Lj USE OF 9 (commencing with Section 7000) of Division 3 of the Bust- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and J CONNECTION CHARGE FEE effect. CONTRACTOR/*" -Ile License Number 0 f Lic.CIOSs ADDRESS l py REIMBURSEMENT FEE DISTRICT NO. GROUP MAP PROCESSED BY O Conlractorf y ; -f I kl)ate CITY TET.NO F T BK PG y El am exempt under Sec. of the L.A.Co. SCENSE NO. '� [� 7 TALIC.ASS :G? �� OC O Plumbing Code and/or Sec. of the Na DESCRIPTION OF WORK FEE FINAL ,z V *HOUSE SEWER CONNECTING TO Jl ,` DATE .,,� ' VALIDATIO W j PUBLIC SEWER B. 8 P. Code for the following reason } ' SEPTIC TANK,SEEPAGE PIT OR Z PITS AND/OR DRAINFIELD FINA -• Date HOUSE SEWER CONNECTING TO BY - y PRIVATE _DISPOSAL SYSTEM Signature 3 +1 - -- CONNECT ADDITIONAL BLDG.OR O N---f��ER-BUILD DECLARATION WORK TO HOUSE SEWER ► OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.55, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code)' SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure x 6 7 911 A is not intended or Offered for sale (Section 7044, Business and Professions Code). OWNERS Permit _ $ Mt -� ! 0 , 1 El 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 21,5y)licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO P - 275 0 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY ry f _7, 0 6 SIGNED THIS DAY F_ /� � 1 I hereby affirm that there is a construction lending agency OWNER OR I, -' for the performance of the work for which this permit is OWNERS AGENT 7 issued (Sec. 3097, Civ. C-). .1 ADDRESS Lender's Name Lender's Address I certify that 1 have read this application 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 rtpresentatives of this County to enter upon the above-menttonealproperty for inspection purposes. Sigpdture of Pe''rm-t a Date SEE REVERSE FOR EXPLANATORY LANGUAGE -WORKERS' COMPENSATION DECLARATION Lei a M*•I herefu Affirm-that U have a oertificate'of consent to seif insure',dor a certificate of Workers'Compensation Insurance, or %6A642D a cert,fed copy thereof (Sec. 3800, Lab C.) _EB�B(REV ,1931 APPLICATION FOR PERMIT Policy No. ! Company f,AJ13 ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date `y' "'- )Applicant :K-A,+ :' FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING t ( "�, STATION DEPTH COMPENSATION INSURANCE ADDRESS ` - (This section need not be completed if the work involved by th-i ,�' MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY LOWER that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM I certify P GROSS ST. Y. CURB P.I, M.L.TO P.L. 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. ADDRESS ' Z) Or ! TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant T AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY TELNO 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 BLDGS PERMIT No. SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR r^ .0 CONNECTION CHARGE FEE License Number O Lic.Class 4 ADDRESS �p REIMBURSEMENT FEE Contractor l DISTRICT NO GROUP MAP PROCESSED BY O {� ' L' j 1 Date r �!' 1r '� A CITY y TEL NO. � \ t1 A BK PG /� v ❑ I am exempt under Sec. \of the L.A.Co. LICENSE NOTATE t CLASS " f o NO. DESCRIPTION OF WORK FEE (— Plumbing Code and/or Sec. of the FINAL ' i V HOUSE SEWER CONNECTING TO DATE PUBLIC , zj{�.� VALID TION LU SEWER B. 8 P. Code for the following reason H SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD BY // / Z Date HOUSE SEWER CONNECTING TO r1 PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ► OVERFLOW SEEPAGE PIT,DRAINFIELD 1 hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM fessions Code): �❑ I,as owner of the property, or my employees with wages as rz 7 " their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit g ❑ 1, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 1 9 4(� A licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO {�.0 0 0'S {� Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19o � for the performance of the work for which this permit is OWNER OR 1 5 iL OWNERS AGENT �` J issued (Sec. 3097, Civ. C.). r� ADDRESS U 6,2i87 Lender's Name Lender's Address 1 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 IawS.tregulating Plumbing and Sewers, and hereby authorize re tesentatives of this County to enter upon the above-mnntio d property for inspection purposes. r �p Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE