The URL can be used to link to this page

Home My Public Portal About5635 PAL MAL AVE_Sewer__ WORKERS COMPENSATION DECLARATION pD ppst DPW N09 I hereby offlrm that I have a certificate of consent to self ]BA642o ,,sure o,a ceatificoTe of Workers Compensation Insurance or ad copy Thryeof (Sec lab C ) APPLICATION FOR PERMIT Palltarycy N Na companyny SEWER - SEWAGE DISPOSAL LlCertifiedcopy Is hereby furnished ❑ Certified copy is filed with'the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department L Date Applicant FASSESSOR OR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS omcCOMPENSATION INSURANCE Ess /� STATION DEPTH (This section need not be completed if the work Involved b Thr UPPER y LITY it MANIfIXE REFERENCE - IOWfR permit Ps far one hundred dollars ($100) or less ) LENGTH FROM EST TYPE OF CONNECTIONcertify that m the performance of the work for which this s sr `TIji r cuRB PL ML roPL permit is issued 1 shall not employ any person in any manner GAL n vC No so os to become subject to the Workers Compensation Laws RI PTION LOT NO 7 / Co IMP NO loo No K TRACT �.- TRUNK PERMIT NO ROAD PERMIT NODaleApplicantNOTICE TO APPLICANT If after makin thPs Certificate Of SSOR AFFIDAVIT WAP VER EASEMENT RECORD IN5TR NO DATE 9 BOON PAGE PARCEL Exemption you should become subject to the Workers NO OF BLOGSCompensation provisions of the Labor code you must forthwith OF LOT (�j NOW ON LOT HwY OR ST WIDFN1NG comply with such provisions or this permit shall be deemed Frevoked INGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION �/ PERMIT NO I hereby offlrm that I am licensed under provisions of Chapter ER 9 (commencing with Section 7000) of Dwislon`3 of the BUsi )3� O ' cu0.nessOnd Professions Code and my,license Is In full force and ESS '� /oki/1 �{. CHARGES effect x CRT I TEL NO�(. ��'("(J CCNNECTPCN CHARGE FEE License Number LIC Class REIMBURSEMENT FEE CONTRACTOR Contractor Date DISTRICT NO GROUP MAP PROCESSED By ADDRESS BK PG �o� 3 } ❑ I am exempt under Sec of the L A Co Airy TEL Na �jf��aG�p-C� CC Plumbing Code and/or Sec _ of the ? STATE LIC HNAL U LICENSE NO CI-Ass DATE �V(_ I R_ lygTly]ATION = B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE V— VaJ ��. HOUSE SEWER CONNECTING TO HNAL J 20 Date PUB41C SEWER BY W 1 ITEM SEPTFC TANK SEEPAGE PIT OR Signal Ure PI TS AND OR GRAINFIELD '} a OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING TOPRIVATETOTAL PRIVATE DISPICT SYSTEM I hereby affirm that I am exempt from the Contractors License CONNECT ADDITIONAL BIW OR CHECK 57.20 Law for the following reason (Secton 7031 5 Buisness and Pro WORK To uOGSE SEWER es acs Code) OVERFLOW SEEPAGE PIT ORAINIIELD CHANGE .00 E.TN CESSPOOL DRYWELL MANHOLE 4f1�111VG VU 1 as Owner Of the property or my employees with wages as ALTER REPAIR OR ABANDON HOUSE (heir sole compensation will do the work and the structure SEWER OR DISPOSAL SYSTEM is not intended or offered for sole (Section 7044 Business and Professions Code) 1 ❑ I ITS Owner of the property am exclusively contracting with lcensed contractors to construct the project (Sec Ion 7044 OWNER'S Permit $ n Business and Professions Code) AUTHORIZATION I TOTAL FEE d CONSTRUCTION LENDING AGENCY I HAVE AT IHPS DATE A CONTRACT WITH THE HEREIN NAMED CONtNACIOR TO I hereby affirm that there PS a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBIC SEWER for the performance of the work for which this permit is issued (Sec 3097 Civ C ) SIGNED THIS_DAY CF_19_ OWNFR OR Lender s Name OWNERS AGENT Lender s Address ADDRESS I certify that I have read this application and state that the above PnformatIOn PS 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 above mentioned property for inspection purposes --k $�� ign ur of Permittee // Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS COMPENSATION DECLARATION 76A642D CE 60612601 APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self SEW ER-SEW J,GE DISPOSAL msure or a certificate of Workers' sahon ur of/ d� e^�P ertifl�cow J�py the e¢f 38 L 7 COUNTY OF LOS ANGELES BUILDING AND SAFETY �i o pan y� ❑ Certified copy is hereby furnished �1"�—^� FOR APPLICANT TO FILL IN CONNECTION DATA ® euuDlNc �/ I Certified copy Is filed wrth c ty build. DEPTH ldl pe loin ADDS LOCALITIT Y depart a MANNOLQ REFERENCE UPPER Date / Applicant NEAREST TYPE OF CONNECTION LENGTH FROM LOWER CERTIFICATE OF EX ION FROM WORKERS' CROSS IT v CURB P L M L TO P L COMPENS T N INSURANCEP C NO OWNER �� CO IMP NO JOB NO (Phis section need not be coin leted If the work involved MAIL `• D ADDRESS G I�i TRUNK PERMIT NO ROAD PERMIT NO a by the permit Is for one hundred dollars (5100) or less) FF,OA,,, W,w.N SA.B,IBNT R memo 'MST" No BATE O clTr Mi, No U I certify that In the performance of the cork for which this LeeAL permit Is Issued, 1 shall not employ any person in any manner DESCRIPTION LOT No Hwr oR er WIDENING so as to become subject to the Workers' Compensation Laws 0 BLOd. TRACT STATE ENCROACHMENT I— DateApplicant NO OF BLDGe FQRMIT No W NOTICE TO APPLICANT If after making this Certificate of SIZE OF LOT Now ON LOT Exemption, you should become subject to the Workers USE OF CHARGES 2 Compensation provisions of the Labor Code you must forth BUILDINGS _ with comply with such provisions or this permit shell be AZ7CONTRACTOR l / CONNECTION CHARGE FEE deLmed revoked � �✓�I LICENSED CONTRACTORS DECLARATION ADDRESS IS9,d REIMBURREMENT FEE 1 herebv affirm that I am licensed under provisions of ChapteroISTSICT NO BNOu. MAP A .Seem EO RT 9 (commencing with Section 7000) of Division 3 of the Rust CITY TEL NO — _r Y RH PG ness and Professions Code and my license is In full force and iLTATELIC ICENSE NO 7 CLASS CDU effeLt NO DESCRIPTION OF WORK FEE ROUSE FINNL VALIDATION License Number �C Lic Class 7 ewe NN.cTINC To FINAL DATE oR Contractor ....0 NNECTI a FINAL J l / N'ou amnf• R CONNECTING nae T BY PRIVATE DISPOSAL ❑ 1 exempt from the bcensmg requirements as I am a CONNECT ADDITIONAL BLDG OR I nsed architect or a registered Professional engineer acting m my professional capacity (Sechon 7051 BusOVERFLOW SEEPAGE 11 DIAI�11.1-. (/SI(Q (ness and Professions Code) EX TR CffSSPOGL DRYW E LL MANHOLE ALTER REPAIR OR ABANDON OUSE Lic or Reg No Date HOME OWNER BUILDER DECLARATION ;9 G 1 2 1 A I hereby affirm that I am exempt from the Contractors OWNER'S Permit f # . . . . 1 0 License Law for the following reason (Section 7031 5 Bust AUTHORIZATION TOTAL FEE ness and Professions Code) E w Is CATS .REIN n [ 1 7.50 I HAVE AT THIS ABOVE O RSCRI...axuTlna NAMED ❑ I as owner of the propLrty will do the work and the TO THE PUBLIC SEWER mL i 1 ,75 ,' S 0 structure is not intended or offered for sale (Seltmn SIGNED THIS DAY OF 19 PIIS 7044 Business and Professions Code) OWNER a" I ,z O 1 -81 � _8 .� NESS AGE CONSTRUCTION LI.NDING AGLNCY I hereby affirm that there Is a construction lending agenLy JADDRESS for the Performance of the work for which this permit is ISSULd (Sec 3097 Civ C ) Lender s Name Lender s Address 1 certify that 1 have read this application and state that the above Information Is correct 1 agree to comply wrth all County ordinances and State laws regulating Plumbing and SLwers, and hereby author17e representatives of this Count) to enter upon a ebo menhone pro arty for inspection purpose { SEE REVERSE FOR EXPLANATORY LANGUAGE L r ture of erm tee Date