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Home My Public Portal About6035 PRIMROSE AVE_Sewer__ Ay WORKERS"COMPENSATION DECLARATION n • h hLereey offirrrl thch I have a certificate of consent to self .� • ;insure, of•a:certifieate•.of Wdrkers'Compensation Insurance;or 76A642D a certified copy thereof(Sec.3800,tdb C.) CE e68•(REV.8181) aP P L I C A I O N FOR �� 9`� Policy No. Company as. g�g E] Certified copy is hereby furnished: SEWER a SEWAG. E ®BSPOSAL IV Certified copy is filed with thecounty building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY dear et: ,` y Date Applicant ® Yt:/+,J- Riq1Ler?_• FOR APPLICANT TO.FILL IN CONNECTION DATA , CERTIFICATE OF EXEMPTION.FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS (), srATION DEPTH (This:section need not be.completed if the work involved by.theLpeAttrY ; MANHOLE REFERENCE SOWER permit is for one hundred dollars NEAREST TYPE OFCONNECTION LENGTH FROM ($100.)or less.) I certify that In the performance of the work. for which this CROSS ST. � L.l Y, CURB P.L. MA.TO P.L. permit.is issued, ]snot employ any person in any manner _ P.Cs No so as to become-subject to the Workers'Compensation Laws, . OWNER '- ":AJ4, T54 CO.IMP.NO JOB.NO, MAIL i.,@ TRUNK PERMIT NO. ROAD PERMIT'NO. Date Applicant ADDRESS vv NOTICE TO APPLICANT: If, offer making this Certificate of CITY TEL N. AFFIDAVIT WAIVER EASEMENT RECORD.INST.R,NO. DATE b Exemption, you. shquld become subject to the Workers LEGAL Compensation.provisions of the Labor code,you must forthwith DESCRIPTION LOT NO HWY.:ORST.WIDENING comply with such provisions or this permit shall be deemed revoked. r BLOCK TRACT STATE ENCROACHMENT .LICENSED CONTRACTORS DECLARATION NO.OF BLDGS PERMIT t10. I hereby affirm that'I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT tuEOF 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 effe.at: CONTRACTOR �.K.L CONNECTION CHARGE FEE License Number Llc.Class . ADDRESS REIMBURSEMENT FEE O Contractor DateCITY I�I� DISTRICT NO GROUP MAP PROCESSED BY ❑.1.am exempt under Sec. of the L.A.Co. ' TEL.NO. F j STATE LIC. .. BK PG LICENSE NO. �. CLASS J G - 'OT �� O liv NO, DESCRIPTION OF WORK: FEE_ �� U Plumbing Code and/or Sec,. of the HOUSE SEWER CONNECTING TO DATEFINA / r B. 8 P. Code for the following reason PUBLIC SEWER `. VALIDA�_bm. til SEPTIC TANK_SEEPAGE PIT OR FINAL g PITS'AND/OR DRAINFIELD �+ Date HOUSE.SEWER CONNECTING TO BY s. PRIVATE-DISPOSAL SYSTEM _ (! Signature CONNECT.ADDITIONAL BLDG.OR OWNER-BUILDER'DECLARATION WORK TO HOUSE SEWER , OVERKOW:SEEPAGEPIT,DRAIN..FIELD I Hereby affirm that'I am exempt from the Contractor's License &rN..,CESSPOOL,DRYWELL,MANHOLE Low for the following reason (Seetort 703:1.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code)- SEWER.OR DISPOSAL SYSTEM ' 4673,�r` Q .El 1,as owner of the property,or my employees.with wages as' their sole compensation,will.do the work and the structure ` r ¢. o a o o j 4 Ts not intended or offered for.sale (Section 7044., Business and Professions Code). OWNER'S Permit $ x r o 15�4. r�r EJ 1,as owner of the property,am exclusively contracting with A49THORIZATIOIN TOTAL FEE Uff 4 licensed contractors to construct the project (Section 7044, I HAVE.AT THIS DATE A CONTRACT WITH THE.HEREIN NAMED CONTRACTOR TO a .q 1 J ,u •) Business and Professions Code). CONNECT THE ASOVEDESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER, CONSTRUCTION LENDING AGENCY "8 7 ;I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the .performance of the work for which this permit is OWNER NER6 AGENT f issued(Sec. 3097, CIV. C.) ADDRESS. Lender's.Name Lender's Address I certify that I have read this application and state that the above information is correct. .II•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 pr erty for inspection purposes, Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE 1� f kRKERS''COMPENSATION DE RATION f hereby-affi.r? 1Kdt 1'hove a certificat of consent to. self �-,.insure,"of a'cettificate•of Wdirkers'Compe ation Insurance,.or 176Ae420 r a policy ied.copy thereof(Sec. 3800,16b C..,) CE BDB(REV,a/BI): �"' ATIO' �®o PERMIT Policy No.Company ;.es L DIU L�+Et�i C9 ❑ Certified copy is hereby furnlsfTed. SEWER " SEWAGE DOSP®SAL J9 Certified copy:Wfiled with the'.county b .I.ding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. 1 Date. L d".Applicant. FORAPPLICANT TO FALL IN CONNECTION DATA CERTIFICATE OF.EXEMPTION FROM NII KERS' BUILDING .�s d STATION DEPTH COMPENSATION INSURANCE 1 ' ADDRESS (This section need not be completed if'the work volved.b the i i fi UPPER y MANHOLE REFERENCE permit is for one hundred dollars($100)or less. LOCALITY LOWER NEAREST .ATYP.EOFCONNEC710NLENGTYiFROM I .certify that in the performance of the work r which this ;CRO55 ST, Y. CURB P.L. M.L.TO P.L. permit ts.issued, 1'.shall iioT employ any person % any manner p•c-NO. so as to become subfect to the Workers'COmpens ti.on Laws. OWNER CO.IMP.NO. JOB NO. ' i MAIL i .TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant :•ADDRESS NOTICE TO APPLICANT.: If. after making � AFFIDAVIT WAIVER EASEMENT RECORD;INSTR,NO. DATE . this Cer.1tflcate .of eITY TEL.No. Exemption,. ,you .shou.ld become subject to the.'Workers' LEGAL Com.penscition.prov.'islons of:The Labor code,:yaU.mUSY forthwith DESCRIPTION LOT Nb.• .; HWY OR:ST.WIDENING comply wifh such provisions or'this permT'j shall. be.deemed. ; revoked. - ''BLOCK _ TRACT STATEENCROACHMENT LICENSED.CONTRACTORS DECLARATION, NO..OF BLDGS'. PERMIT'NO. . ( t SIZE.OF LOT NOW ON LOT �y I.hereby affirm that I am licensed under provisions of Chapter aeOF Li�. at�j` (! �P1040 9 (commencing,with.Section 7000.) of Division 3 of the Busi-. BUILDINGS CHARGES ness and Professions"Code, and my license 'is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE License Number Lit.Class r REIMBURSEMENT FEE O .ADDRESS _ Contractor Date DISTRICT NO. GROUP MAP PROCESSED BY CITY 'TEL.NO. Jr� BK PG z. STATE r. LIC. _ ❑ I am exempt under Sec. of the L.A..Co: LICENSE NO CUSS �r vJ• !� �� Plumbing Code and/or Sec; of the. NO DESCRIPTION-OF WORK FEE: FINAL. Ly HOUSE SEWER CONNECTING TO ;DATE VALIDA. IO.N B. &P Code for the following reason PUBLIC SEWER — � SEPTIC'.TANK,SEEPAGE PIT OR � L. z PLT.S gND.90&''DRAfNF1ECD Date _ HOUSE.SEWE(t CONNECTING TO r ' � tf( PRdVATE'DI POSAL.SY$TEM• Signature 1 CONNECT ADDITIONAL BLDG.09 ' OWNER-BUILDER DECLARATION WORK TO HOUSE:SEWER OVERFLOW''SEEPACyE'PIT,.DRAINFIELD z 4 1 hereby affirm that I am exempt from the Contractor's License EXTN„CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, BuiSrlets and Pro= ALTER,REPAIR.OR ABANDON.HOUSE fessions Code)= SEWER OR DISPOSAL SYSTEM96745-A ❑ I,as owner of the property,or my employees with wages as 0 0 0,o,t 0 their sole compensation,will do the work and the structure is not intended or Offered for sale (Section 7044, Business ( 0 0 2 7.5 and Professions Code). OWNER'S Permit $ ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE0 0 0 ,^-7.5 J licensed:contraCTors to.construct'the project (Section 7044, .I 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. .0 125-87 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a •construction lending agency SIGNED THIS D'AY.OF 19_ ' for the performance' of the work for which this permit .IS OWNER OR issued (Sec..309.7,.Civ,.C,). OWNERSAGENT, - - - ADDRESS, Lender's Name .. Lender's Address I 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 laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned p perty for.inspection purposes: P Signature of.Permittee Date ; SEE REVERSE FOREXPLANATORY LANGUAGE ;