The URL can be used to link to this page

Home My Public Portal About5344 PARMERTON AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby offirm that I have a certificate of consent to self insure or a cert,flcote of Workers'Comyyy a isabon Insurance or �eAatao - .y�e�lLfjCa (Sec 3000C , ` B�1REY a/ell 'APPLICATION FOR PERMIT Company s -- ❑ If led copy Is hereby furnished - SEWER - SEWAGE DISPOSAL ' Certified copy Is filed with the county building Inspection COUNTY OF LOS ANGELES b BUILDING AND SAFETY ? dep rim TO DaApplicant FOR APPLICANT TO FILL IN CONNECTION DATA ' ERTIFICA7E OF EXEMPTION FROM W KERS BuuoING �y - COMPENSATION INSURAN - ADDRESS sTAnoN' - E DEPTH /�O (This section need noot be completed if the work Involved by the LocnuTr MANHOLE REFERENCE r - UPPER ' pe`rmit is for one hundred dollars (1100)or less ) - LOWN 1 certify that In the performance of the'work for which this cRAOss sr S • TYPE OF CONNECTION PAL THP L Y NqB PL ML TOPI , perm It Is Issued 'I shall not employ any person In'any To PC NO me so as to becosubject to the Workers Compensation pensaon Laws , OWNER ' co IMP No Los NOA+ MAIL RESS • TRUNK PERMIT NO ROAD PERMIT NO - Date—Applicant W NOTICE TO APPLICANT If ofter,making this CertifimAFFIDAVIT ANER EASEMENT RECORD INSTR NO DATE te of CITY L No Eeemption you should become subject"to the Workers �� Compen3Oh On'provtsions of the Labor codeyou must forthwith DESCRIPTION - LOT No HWY OR ST WIDENING _` ^ comply with such provisions or this perm It shall be deemed revoked - ' BLOCK TRACT - STATE ENCROACHMENT , LICENSED CONTRACTORS DECLARATION w OF BLDGS °EWrT NO . A 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 Bust BUK GOIARGES ness and Professions Code and my license Is In full force and -Affect • / CONTRACTOR CONNECTION CHARGE FEE o LI en 68r_ ` Llc Cl SS V•� T Y — REIMBURSEMENT FEE e Q DISTRICT NOIOUP MAP PROCESSED BY❑ 1 am exempt under Sec of the L A Co Si�HSE No act —� d /i3 Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE 1 09NAL VALIDATION PUBLIC SEWER HOUSE SEWER CONNECTING 70 DATE IL B 8 P Code for the following reason 5EV1IL TANK SEEPAGE RT OR FIN r ! - PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY WIVATE DISPOSAL SYSTEM A Signature CONNECT ADDITIONAL BLDG OR - OWNER BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor s License EEXTIN O�RFLCESS�OL DR LL PAGIE IYWE° tAANHOLE n Law for the following reason (Secton 7031 5 Buisness and Pro ATTER REPAIR OR ABANDON HOUSE ' fessions Code) SEWER 2SPOSA&SYSTEM , ❑ I,as owner o4 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) OWNER'S Permit $ • ❑ I as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE 5- licensed contractors to construct the project (Section 7044 , L HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER 5 3 4 6 A CONSTRUCTION LENDING AGENCY hereby affirm that there is a rhlending agency — # •_• • • 5 for the performance of the workk for for which SIGNED THIS DAY OF 19 C1 ch this permit Is OWNER A i Issued (SBC 3097 Civ C ) OWNERS AGENT ADDRESS _ 'III •1 5Q00 t lenders Name • - 1 5 4,0 0 5 Lenders Address • r ' I certify that I have,read this application and state that the _ 0 Q 9 2`8 6 'above Information Is correct I agree to comply with all County ordinances and State jaws regulating Plumbing and Sewers and Pereby authorize representatives of this County to enter up the ve-mentioned property for lnspe o purposes - nature of Permtheir REVERSE FOR EXPLANATORY LANGUAGE ' ' WORKERS COMPENSATION DECLARATION I hereby of9rm that 1 have a certificate of consent to self Insure or a certificate of Workers Com sation Insurance, or 76AM20 P ' , �m�38 CE BOB B'B" APPLICATION FOR PERMIT , ❑fCentified copy Is hereby furnish ,///-� SEWER - SEWAGE DISPOSAL I ' ® Certified copy is filed with t cou y bin m inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY dap me � Date an FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WO ERS COMPENSATION INSURANCE TAMR� STATION DEPTH14(This sectionneed not be,completed If the work Involved by the MANHOLE REFERENCEuPrfR permit Is for one hundred dollars (S10D)or less ) nPE OF coNNEaIDN LFr.1GrH Front I certify that In the performance of the work for which this G Y CURB PL ML TOPL permit Is Issued, I shall not employ any person In any manner pC NO so as to become subject to the Workers Compensation Laws CO IMP N , JOB NO TRUNK PERMIT NO ROAO PERMIT NO Dote Applicant AmREss NOTICE TO APPLICANT If after making this Certificate of Cin. AEFlDAVIT wwrvER EA56•nENr RECORD IrRSTR rR0 DATE Exemption you should become subject to the Workers„ ' Compensation provisions of the Labor coda LEGAL p p you must forthwith DESCRIPTION LOT No comply with such provisions or this permit shall be deemedHwY GR ST WIDENING� revoked BLOTQ STATE ENCROACHMEM LICENSED CONTRACTORS DECLARATION NO OFBL PERMIT SIZE OF LOT rRo I hereby affirm that I am licensed under provisions of Chapter' u5E� 9 (commencing with Section 7000) of Division 3 of the Busi- BULLRINGS CHARGES ness and Professions Code and my license Is In full force and eft''��jj//t14`/ ,J/1 C CONNECTION CHARGE FEF LICenSe�Uri LI< l.r9it-_�_ ADDRE REIMBURSEMENT FEE O I RIOT NO GROUP MAP FROCFSSED 8Y V Y T SK PG O LiC. S; 0 fi �3 G �� r ❑ I am exam under Sec of the L A Co V NO DESCRIPTION OF K FEE Plumbing Code and/or Sec of the DAE VALIDATION 1 HOUSE SEWER CONNECTING i0 DATE B 8 P Code for the following reason Puatx SEWER to SEPTIC TANK SEEPAGE LPITD OR NTS PIJD/OR DRAINFIELD FINAL � J Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR OWNER BUILDER DECLARATION WORK To HOUSE SEWER I hereby affirm that I Om exempt from the Contractors License EOVERiFLOW SEEPAGE PIT DRAlELL l'NFIELD CESSPLaw for the fallowing reason (Secion 7031 5 Bwsness and Pro- urea REPAIR OR ABANDON HOUSE fewicins 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 , Is not Intended or offered for sole (Section 7044 Business and Professions Code) - OWNER'S Permit - $ (f - ❑ 1 as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE pZ'f licensed contractors to construct the project (Section 70L44 I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAA1E0 CCNTRACLOR i0 BUSIDelS and PSTCode) CONNECT THE ABOVE DESCRIBED MSTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a Construction lending agency SIGNED THIS DAY OF 19_ , 2534,7A for the performance of the work for which this permit Is OWNER OR issued (Sec 3097 Civ C ) OWNERS AGUNT # • • 1 0 AnoREss Lender s Name ,I • • 2Z50 _ Lender s Address . * 27505 275O5 1 certify that I have read this application and state that the above Information Is correct I agree to comply with all County Q 9 2 $6 or mantes and State laws regulating Plumbing and Sewers a d hereby authorize representatives of Is County, to enter u n enhoned pFpperryform echon rposes `r Signature of rm Ittee ate `�� SEE REVERSE FOR EXPLANATORY LANGUAGE