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HomeMy Public PortalAbout6017 PRIMROSE AVE_Sewer__ WORKERS'COMPEINSAV01N DECLARATION. �j Z0E105TDPW 61�.9 1 here.by' affirm: that I have a certificate of consent fo• self' UU rAs0i;0,•or a cerlificote-of Workers'Compensation.16.Su.rance.,or 76A.E42n p p�(� r q� p�p,(� PERMIT a serrifieif capy `hereof(sec.°36110, lab C.) 6% ff"L1CA if 0'N FOR l���RMIT • policy No Company _ u v Certified copy is.'hereby furnished SEWER SEWAGE DISPOSAL F1 Certif:red copy. Is Bled-with the county building mspr vi.on COUNTY OF LOTS ANGELES SUI.LDING AND SAFETY department. .Dote Ap•pl,icant — -- FOR APPLICANT TO.FILL lid CONNECTION DAT.A�. CERTIFICATE OF EXEMPTION,FROM WORKERS' . . ,cr �do i $fAThE DEPTH COMPENSATION INSURANCEbf' 7h.ts sec+ton need riot be cd.m leted if:the work involved b the. P' ( . p: y : r .� �� MANW66E.REFF'RtNCE ��''///may permit.is for-cine hundred dollars ($100)or less:,) LocaLlTv +A -/J. ° LOWER NEARIST I- .L r^by4gy. TYPE OF CON ON. LENGTH FROM I certify that in the performa rice of the work for which this CgosssT A; L G / � v C Rtt PL MI Td'P't permit-is issued,.i shalt not employ any person in-any nTo.nner LEGAL, PC Na so'as.to beto.rne subject W.the.Workers'Compensdtion Laws: DESCFtlPTIC1N LOT NO CO.IMP'NO JOB NO ' Date Appllcont•, .BLOCK TAAC.T TRUNK PER74,T NO ROAD PERMIT;NO - . l ASSESSOR. ./,1�.✓ if AfFIOAVI.T WAIVER EASEMENT RECORD INSTR NO DATE NOTICE TO APPLICANT- If, offer moki+ng this. Certificate: of MAP'BOOK w��J .? PAGE �D• PARCfiL 'Oil E'x.emption.,, you should become subject to. the Workers' N.Q.OF BLDPiS. CO.mtiensotion provisions:af.the Labor code, yUU must forthwith ; SIZE OF LOT' NOW ON LOT HWY OR ST WIMNINC+ -comply with such provisions or 'this permit shat! .be deerri.ed uSEpF ' revoked, BUILDINGS - .STATE ENCROACHMENT ' LICENSED CONTRACTORS.DECLARATION /�r /7 tS al�� 1�, PbRM6$NO I hereby affirm that I.am licensed uhder proviewhs.of acipt:er O.WNEfI G �t,� io6fv.r"" �.. 9 (cornmenc.i.rlg.with Sec•tio.n .7000.) of Division 3 of the Busi- Mail t% (� ,C•,LJA t.. 'sco LI,J ness and Professions Code, and my!..;cense is in fu'l:l force.and � ADDRESS ( ¢'] 1 1 CHARGES effect. ' CITY ` i°� G 7fL.ND. \ `f �r C S j CONNECTION CHAOGE FEE L.Lcense Number Lic.Class RUMBURSEMENt EEE, CON.TAACTOO F Coniroc.ior Date DISTR;C7 NO ROIIF MAPPR $ BV :ADDRESS,. �; BK RG ❑ I.am.exempt under Sec. of the L.A.Co. ,�: CITY TEL.NO. O Plu.mbingCode and/or Ser of the STATE Lit;. FINAL "V • LICENSE NO CLASS. DATE VALIDATION � B. &P. Code for thefOl:lawi.ng reason NO. DESCRIPTION OF WORK' FEE' HOUSE SEWER CONNECTWO TO A't FINAL k- Ante; R.IBLIc gwfR ty' 8Y V SEPTIC TANK SEEPAGE PIT OR { W CL 5ignalure P,TS AND CTR DR.AINF.IEL'O N OWNER-BUILDER.DECLARATION HOUbE SEWER CONNECTING TO LYrAiE D.ISPOSAI SYSTEM I hereby affirm that I am exempt from the Contractor's License CONNECT At7Dnt0N'AL BLDG. QR Law for the fol'I.owi.rig reason (Set ton.7031.'5, Bu sness and Pro- i"Opx Tq t�.usE UWER .OVERFLOW SEEPAGE PIT DRAINFIELD r ' fession5.Code)'. i .ENTN.•CESSPOOL DRYWEU MANHOLE: C1 I;.0S Own@r'Of the property, or rmy employees with wages a5 Af.TER REPAIR O:R ABANDON.004 t SEWER OR.6KPQSAL SY5Tt rA' their sole'Compensat:ion,will do the work and the.structure Z. ` !Is not in.terid'ed or offered for.Sale (5ecil.on 7044, Business ' and Professions Code. -• I,as owner of the property, am exclusively contracting with C ri onfractors ro Construct the rajeCl (Seerion 7044, , O'FR/iNER'S Permit licensv $126 d _ t p 2 a ( Business eAd Professions,Code.); AUTHORIZATIONI TOTAL SEE ' CONSTRUCTION LENDING AGENCY aT THIS DA iE A E{�hJii 6f WitH THE HEREIN NAMED CONTRACIOR T3 i hereby offirrn that there is a tonstr.Uction lericling'.agency COiwNFCTT?gEnBOVE.i3)SCWSWExiSTINEz�TDvfUI 1..©.NtPUBL,C$FWER � ry„t �n for rhe performvncii of the work for which this Permit is issued:(.Sec, 3097, C:iv. C.), SIOWD.THIS DAY OF CJWNER.PR •' . Lender's.Name OWNERS.AGENT fi Lender's Addr.. --- -- -- :t Al ' ADDRESS I certify that.1 have read this dppliciittcr, and state that the above inforrriatton is correct...!agree to Comply wail 01'1'EO'unty f•="'' � I o:rd1na.rlce5 and. Stole Laws regutoti:ng Plumbing and Sewers, and hereby authorize represe..nloflves of this County to enter :uipo'ri the above-mentioned property.'toy'inspect.iorr purposes. 519not6re of Perirfitlee. Date, SEE REVERSE409,EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION 20^13051 DPW 6Tt19 1 her.-A ETffi.rm"tha:t I hove a rtZrli.flcate .of consent to: self !j �gAl�a2D Insure„.or a certificate.of'Worke's,Ctimpernation Insurance, or /� m j 5� [� (� y o csrrrfaed cagy thereof (sec 3800, LAC r: i ����8��I] �,�� FOR ��IRL�� fl }.,oI)cp,Nb_ Cornpnny �GE�= �q �'�t�. p�/ pdt�p {Certified copy Is hereby furnished I SEWER ` SEWAGE DISPOSAL [ 'Certified.copy Is fried with 1. .- c my kivilding �rte. ct, n COUNTY OF.LOS ANGELES BUILDING AND.SAFETY department 1 _ pate._Applicant, FOR'APPLICANT TO FILL I. CONNECTION DATA CERTIFICATE OF E'XEMPTI.ON.RO. WORKERS.' BI)ILDING COMPENSATION INSURANCE I ADDRESS J rF''Q� TATION DEPT8 (Thissecfion.need not be comple+ed If rhe•work-Inwolved b.y l',e I LOC !j� ` MANHOLE REFERENCE PPE R perrperm-i! Is'for one hundred doflors($100)or less.) -LOCALITY ez ' NEAREST -TYPE OF CONNECTION tENGTH FROM I t•eruf.y. that: in. :ihe performi ince .of the `:vofk for which this ORO.sS 9r. V: CURB PL M t Top! permit is issued, I shall.not employ any person in any:manner 1 LEGAL_ P C NO spas to become•sublea to the Workers'Ccih�pensotron Laws.. ! DFS;CRIPTION LOT NO 'CO :MP NO JOB NO • a - $LOOK TRA'C'T TRUNK PERMIT NO RTyAD?ERMiT NO Dale Applicont NOTICE 7O' .E1PPLICAIVT; If, after makin this Eerl,rf:rCafe' of A5SESSOR r�f!�� '] ��g AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE '3 I MAP BOOK J--In PA0 /. PARCRLL•r�/ Exemption, you- should become 3ub•}ect to the Workers' .'NO.6F BLUG$. Compensation provisions of the Labor code,you.must forthwith S12E OF LOT NOW.O.FI'LOT HWV OR ST'WIDENING, corr4plyi .vvah such prov:l.sl.orls:•or This permit shall be�'deemed ''us�OF revoked., BUIL D+NGS .5;A?.E ENCRQAChMENt LICENSED CONTRACTORS DECLARATION PERMIfNO I:hereby affirm i.fiat I Qm licensed mndei pro.vLsf.orls of'Cfiapte:r OWNERt.• ' , .�yr 9' (commencing with Section 7000) of Division .3 of .the B.usi• MAIL A.DORESS, .. CHARGES ness.and Professions Code, and ml/lic.e.n.se is,.n full.force and .effect e'er O(_ f,A •. ` TEL NO. GONNEtrION.CHARGE FEE C1TV• , Wi�gg,, rro�.y License.Number2 r Lic..Class 44�ZI REIMEIURSEMENT FEE ;) CONTRACTOR .;L//.(,�;'. ' ', Z ��`40- 007410-NO ''GR.OUP MAP' PROCE55E4$r Contractor 'Date { ADDRESSe BK PG 0 I'om exerrtpt.urlderSec, of t.h.el.A.Co.. I�: ':cay ' } } e py +�y, � fff' 11 i w EL.F10. �s'�, � �� of 9 ��� ✓ � �'�+� Plumbing Code and/or Sec.. of the I STATE,` cLIC. FINAL. V .I LICENSE NQ. Sg�g•� �. , CLAS,5 - OaTE qVALIDATION.. 'r ' B.: 9.P. Code.'fat the fallOwl.tig.reason _ .NO. .DE6CRIP710N OFIIJORK FEE ' ”. � . d HOUSE St WER CONNF.,:T'ING TO .'FINAL Date PUBLIC UwE.R BY bEPTtc TANK.:SEEP:'\Ci,E PIT'CIR IL Sign.oture - { ' PITS AND OR OR 0iELD :;;�,� :.y.r cy�•: O NER-BU.I.LDER'DECLARA lON HOUSE.SEWER'CONN 'I To •I PRIVATE DI$POS'AL Sr,TEM I hereby.affirm that.I am exempt from the Contractor's License l GONNECr ADOITI¢,tiNrLL BIOG OR I r t.1Low for the follo�n.g reason(Sedan 7031 5,Bu:isness.and Pro.• { WORK TO HOUSE SEW Fit _ y _ fessions Code'. OVERFLgV EEP 4GE PIT U.RE1i.tuCAELU ;3 :IL ,�y3 ♦;�; {I F:IC?ty. CtiFS�ODIORF.WF:it,dnA'FiHCJLE 1Q -' --t as owner of the property;or my employees with wages as ALrFR. AN.DON HOUSE !''f } ;'l = <•• I❑ I0WAIRK.WFRDR(SISP0501. �yST.EAy. their,sale car rpe.nspt.iom.will d'a the work arid.the strpot.u.re NSA •, } Is not.intended or.offered for.sole (Sec�t.ion 7044, Bu.smess °s f,' 313 and Profess.lons Code) II _ .0 I,os.QW.ner:of the property,am e;itclusively1conttacting wl;th OWNER'S Permit. S• ' t.Y... .- -�� ry:: licensed'C:OntraClors t0 c6nstruCt the prolecf (Section 7044, ;I Business and,Professions Code), AUTHORIZATIONTOTAL FEE /e'er F'r� iC-NI .. t Opti 1 d"fa y "E CONSTRUCTION LENDING AGENCY � l HAVE AT a'THIS DATE CONTRACT Wlrrt THE HFRFIN nid'ni.EO CCFJt.ftACJOR its t hereby affirm that there Is a c:Ortstruchon lending agency CONNECT rW ABOVE OESCRISED FXiST,NG'TJWFILING TO THE PuB11C SEWER for the performance .of the work for which this permit issued(Sec. 3097,Civ. C..), 5-JONEDTHIS DAV.QF 19_ CAYNER OR Lender's Name _ OWNERS AGENT. Lender's Address ADDRESS I certify thpl I hn.ve read this..oppl.Iciirtttn and state thor the. above information IS corrPCt. I agree to-Comply.w'fh.a1'}County ordinances and State laws regulating Plumbing and Sewers, and hereby aulhortze mrepresentotives 'of this County,,to e.t)te.r upon S. ve-mentivned prapy or Irtspeclibti,purposes i ]. e �_ . yl e4 S'ignatupof Permifiee Dote sEt.RE,VERSE-FOR EXPLANATORY LANGUAGE