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Home My Public Portal About10621 OLIVE ST_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a,certificate of consent to self insure, Or a ce,rtifiegte f.Workers'Co pensation Insurance,or 10AG42D a certified copy there (Sec. 3800 C. 7 82-0002 DPW 6/86 AIPPLICATION ®W PERMIT Policy N i "Company El Certified Certified copy is hereby furnished. I SEWER m SEWAGE DISPOSAL acertified copy is filed with the county building inspection 1 COUNTY OF LAS ANGELES i BUILDING AND-SAFETY cIart menC.C. :-- Dote Applicant i�n` "��'f I FOR APPLICANT TO FILL IN CONNECTION.DATA CER.IFICATE OF EXEMPTION:FROM WORKERS' BUILDING •J ,•� STATION /'�' DEP1H COMPENSATION INSURANCE ADDRESS {s !/ ,7 11 (This section need not be completed if the work involved by the II : LOCALITY yam'fes,r MANHOLE REFERENM C, �f ,`:� ^ permit is for one-hundred dollar's($1.00)or less.) f LOWER NEAREST /•' ,j TYPE OF CONN E4'TI1,�,,�} /_ LENGTH FROM I certify that,in the performance .of the work for which this CROSS ST t— ^/° A✓ Y. CL69 " M.L.TO P.L. t permit is issued, I shall not employ any person in any manner I Y / PC.No. so as to become subject to.the Workers'Compensation Laws. OWNER a/IJ CO.IMP,NO. JOB NO. .1 MAIL �- . ;I /" T&UNICPERMIT'NO. ROAD PERMIT NO: ADDRESS DateAppllcont • I _ g•i AFFIDAVIT WAWER EASEMENT RECORD,INSTR.N.O. DATE: NOTICE TO APPLICANT: .If, after making this Certificate of i :i CITTEL. rr f Exemption; you•should become subject to the Workers' tEl. LEGAL Compensation'provisions of the Labor code,you must forthwith q DESCRIPTION LOT NO. ,OR ST,WIDENING comply with such provisions .or this permit shall be deemed, I IT _Y7 BLOCK TRACT STATE ENCROACHMENT , 1 PERMIT NO,. LICENSED CONTRACTORS NO SIZE OF LOT NOW ON..LOTDECLARATION I OF SLOGS. � LOT 1.hereby.affirm that I.am licensed under`provisions of Chapter I USE OF 19 (icomm.(comm. encing. with Section 7000) of Division 3 Of the BUSi- BUILDINGS CHARGES riess and Professions Code, and my license is in full.force and' effect. I .CONTRACTOR � +� {� CONNECTION CHARGE FEE License-Number � Lic.Class 73/ ADDRESS �tQ / ett �'.' ��'- REIMBURSEMENT'.FEE. Contractor DatDate�/'�r I :CITY jf b TE,NO. DISTRICT NO. GROUP MAP PROCE ED'BY • L_ 1 B PG STATE - LIC. ' ❑ I'amexempt-under Sec. of the L.A.Co. ;,LICENSE NO. CLASS O Plumbing Code and/or Ser. of the NO. DESCRIPTION OF WORK FEE FINAL, C 7 PURL E SEWER CONNECTING TO d .DATE VA DATION B. &.P. Code for the following season ,I " O jl SEPTIC TANK;,SEEPAGE.PIT OR FINAL. F- PITS AND/OR DRAINFIELD By G7 Date I HOUSE SEWER CONNECTING TO I Ld I, PRIVATE DISPOSAL 5YSTE a Signature.. CONNECT'ADDITIONAL BLDG:OR rn WORK TO:HOUSE SEWER OWNER-BUILDERbECIARigTIEQN a OVERFLOW SEEPAGE PIT.DRAINFIELD "} I hereby affirm that I am exempt from the Contractors License ! EXTN.,CESSPOOL,DRYIIYF.II.MANHOLE: Law for the follow.'ing reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR ORAIIANDON HOUSE " fessions Code.): ! I SEWER OR DISPOSAL.SYSTEM j El1,as owner of the property,or my employees wifli wages as ' ,G t�G / 1101 their sole compensation,will do the work and the structurev p rGT.4 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit s I 7,3117 217Z 1: ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE ; Y40 1 ITErS licensed contractors to construct the project (Section 7044,. 1 HAVE AT THIS DATE.A.CONTRACT WITH.THE HEREIN NAMED CONT CTOR TO Business.and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER, 'IOIA� 0 TOTAL 49 1 CONSTRUCTION LENDING AGENCY 1– D.t I hereby affirm that L there is a construction lending agency I SIGNED THIS DAY OF 19_ >�' { Lt o•., for the -performance of the work -for which this permit is OWNER OR 1 OWNERS AE;ENT- .L :L:• 1-T` _+.t ' LtrlR°1i4.7'•L, a t)LI Issued(Sec. 3097, Civ. C.). ADDRESS Lender's Nami: Lender's Address } I c;ertffy that I have read this application and state that the ., ,ry NIX.'above in enation is correct. I agree to comply w..•ith all County +� I r r i; 6782. .1 P41I X.'VSs ofdina ces and tate laws regulating Plumbing and Selnrers, I a d h reb. out..Orize representatives of this County to enter U& he a ove.�ITehfioned property for.inspection.purposefr 'ISi nature) f Permittee Date' SEE REVERSE FOR EXPLANATORY LANGUAGE.! ' : -•; %,;= z _ '_ F[ •"i 7 WORKERS'COMPENSATION DECLARATION 20-0051 DPW 6789 I hereby affirm that I hove o certificate of consent to self 76A642tl insure, or a certtftcore of Workers'Compensation Insurance or a terrified copy thereof bm rIy Jab C ) ��'PLICATION FOR 'PER RIa7 iPa.11cy No�`_�```"c 3�C'ompany L'T_�I S�_—_-- -�---- - 'PLICATION vv fJ- �±f1�UC1i3 .. ,,. t�-cerlificid copy Is hereby furnished SEWER ' SEWAGE DISPOSAL {_J Certified copy I', filed with the county budding Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department DateAP.pllcant_ f= i � = `= FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' FAOOAES,� COMPENSATION INSURANCE .3_ , STAt'O'J DEPTH This section need not be com feted if+he work Involved b thP. :y UPPER ( P Y MANHOLE REFERENCEpermit Is for one hundred dollars I$1.00L or less } /r)4.1L �'.. LOWER I certl} that In thP. J. NEAFJEST '�� - T VPC OF CT)NNECTION LENGTH FROM y per:for+rLorrce of .the vvvrk for which this CRO ss FII. .4,10 �` Y CURB PL ML TOP L permit Is Issued, I shall.not employ any person to any manner LEGAL P NO OES so as to become subject'to the Workers'Compensation tgWS UAIPTION. LOT-NO CO IMP NQ 306 NO BLOCK TRACT TRU14KPERMV NOROAD PERMIT NO Dote Applicant: ASSESNOTICE TO APPLICANT If, after maktn this Certificate of MAPBSOK �('' y � AFF IDAWtT wArVER EASEMENT . RECORD�INSTR� NO DATE r) '; MAP BOOK ��/�� PAGE G� nAF.GE• Exemption, you should become sublecr to the Workers' NO OF BLDGS Cornpensotlon provisions of the Labor rode yrau mist Forthwith S17L OF LOT NOW ON LOT Hwy OR ST WIDENING comply with such provisions or this .permit shall be deemed USE OF revoked BUILDINGS STATE ENCRQACHMENT LICENSED CONTRACTORS DECLARATION PERMIT NO I hereby offrrm that I am licensed under provisions of Chapter oWNEA ,'�'`f.E61 -.&40'' v 9 (commencing with Section 7000). of Division .3 of the Busl- MAIL ness and Professl.ons Code, .and my license Is In full.force and :. ADDRESS CHARGES effectp !' t CITY TEL NO CONNECTION CHARGE FEE License Number e/fl y`7r' tic CI055 4�Z �- ti qy REJMB.URSEMENT FEQ . yy CO'aTAACTOR Contractor.!/ �.�rk Date .7� �•L' �� r �� / : DiST�RiCTNOG�ROUP MAP� .PROCESSED BY ADDAEr,S Gfgl [t,Lt a- a .(� C tr BK PG Q I.am.exempt L Oder Sec, of the L A Co . , sr c. � ,•'3� k; � - M CITY . kk&' d TEL NO c�"c: . ,j ^i Ca ` O Plumbing Code and%or Sec ofthe ST UCE36 NO cass DATE VALIDATION a B & P Code for the following reason NO, DESCRIPTION OF WORK PEE. C d r� � �'•• O HOUSE SEVvta;(OM:JCLTi.G TO. // F NAL �• (�- Date RL eI'C SEWE4 BY f+k• •1 a 7t W tiE TIC TANK SEEPAGE PI.T:OR A r,•1 Slranoture__- - PITS AN'J OR ORA NF1L0 OWNER-BUILDER DECLARATION ttqu3E 5Ei'VE4 SAL SYSTEM NG TO .PA BATE DISPOSAL SYSTEM I hereby affirm that I am exempt from -,he Contractor's License 1:V tvFCT ACDITICNAL BLDG OR r y - LOW for the fol•l.owing reason (Secton 7031 5, Butsness:and Pro- WORK TO HCUSE SE+A'EP }" `•"•`;i n-I ;, OVEPFVU W SEEPAGE FIT �'>•,'. •t- :� "•.• fessions Code)` DPAINr'EH _ Ea?N CESStJOOL DRYwfI,.MAt:,'HO�E r•.:T-•r•Js . P P Y.or.my employees with wages as AL•ER REPA.R,JA AS -06SE �• •- 'M1 '��' LJ I,as owner a#the tD er:t 5EWER OR DJSP".AL SYSTEM their sole compensation, will do the work and the structure Is not Intended or offered for:sale (Section 7044, BOSrnc-St ` tt---TT and Professions Code) LJ 1,at owner of the-property,-am exclusively cantracting with n•t;1� t11fia licensed contractors to constr:ucr the protect (Section.7044, LA NERrS Permit $ tt:�':-4.'.;:._* Business and Professions Code). AUTHORIZATION 6' �'T r"t' '' TOTAL FEE i r ! Ail _�," CONSTRUCTION.LENDING AGENCY HIS DATE A r:''tvtRACT w TH THE ViEREIt iAh'EK CQWR'ACPIR TO I hereby affirm that there Is a construction lending agency E A.dOVE DFSCI:I6ED.EXI$TING QWF�,IN3 THF PJB, SEY+FR for the perfolTnnnce, of the work Ior whish rhes permit .Is ,. ,rssued.(Sec. 3097, CIv C ) S r DA , .! •�Lender's Name _ _ raT / & -.aLe.nder's Address — .J I certify 'hot 1 have read thio appli tion and state that the above Information Is correct I agre. t)comply With 0;1 County ordinances and State laws reg.ul Trig Plumblrtg and Sewers, a by o.v.thorite reprr+sent five, of tiilS County to enter t,pon a bove-n+entloned pr eriy roe Inspection purpoSes signature of Perowree ! Date SEE REVERSE FOR EXPLANATORY LANGUAGE