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Home My Public Portal About6037 PRIMROSE AVE_Sewer__ yy. WORKERS''COMPENSATION DECLARATION r Mpreby.offirrq theft Piave a certificate of consent to self ,insure,"ai a:certlficate,.o..f Warkers'Compensation Insurance, or 76A6,47c a certified copy thereof(Sec. 3800,.Lbb C.) CE 808(REV 84.81) AP LIy�.1 F/T��. �.� FOR PERMIT Policy No. Campany �s lC LIlV LN9� �V*tl ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department, Date' __'��pplicant .c a« ,r' ./g FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING STATION DEPTH: COMPENSATION INSURANCE ADDRESS (.This section need not be completed if the work involved by the LOCALITY j MANHOLE REFERENCE UPPER permit is for one hundred dollars ($1Y]0)or less.) LOWER NEAREST TYPE OF CONNECTION (ENGTH FROM I certify that in the 'performance of the work for which this GROSS ST. Y, CURB P L. MA TO P L permit is Issued, I shall not employ any person 'in any rnartner PC.No. so as:to become subject to the Workers'Compensation Laws. OWN�rL >` ,yam i i o IMP.No; POB NO MAIL -` DateApplicant ,ADDRESS TRUNK PERMIT NO ROAD PERMIT NO. : NOTICE TO APPLICANT: If, after makingthis. Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO'. DATE CITY TEL,NO. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the.Labor code, you must,forthwith DESCRIPTION LOTNO .. HWY.OR ST.WIDENING comply:with such provisions or this ,permit shall be deemed revoked. BLOCK TRACT .,STAA ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO OF BLDbS, PERMrr IVO SIZE OF LOT' NOW ON LOT I here.liy affirm .that I am.licensed under provisions of'Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES nese and Professions Code, and my license is in full force and Offect. CONTRACTOR CONNECTION CHARGE:FEE- License Number Lit:Class ADDRESS .av i REIMBURSEMENT FEE Contractor DateC+T.y. TEL NO t►�� DISTRICT NO. GROUP MAP PROCESSED BY U BK PG STATE❑ I am exempt under.Sec. of the L.A.Co. IEENSNO. r.�. .. CQLA SS � O1_ NO. DESCRIPTION OF WORK FEE Plumbing C.ode•and/or Sec: of the FINAL ROUSE SEWER CONNECTING TO. ,DATE d.� ��/�J�� VALIDA I'O.N � PUBLIC SEWER Q B. P. Code for the following reason . . SEPGC.TANK,SEEPAGE PIT OR � � '�� #A PITS ANDxOR DRAINFIELD FINAL. Dote HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEk f Signature CONNECT ADDITIONAL BLDG,OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE.PIT,.DRA.INFIELD 1 hereby affirm that lam exempt from the Controctor'3 License ,ExTN.,CESSPOOL,DR•Y.WELL,MANHOLE Low for the following reason (Sedan 7031.$, Buishess and Pro- ALTER,REPAIR OR ABANDON HOUSE feSsions Code)- SEWER,OR DISPOSAL sYStEM ❑ I,as owner of the property,or my employees with wages as .p 6 7,3'2 A their sole compensation, will do the work and the structure. � � .c ,a a a is not intended or offered for sale.(Section 70.44, Business f' and Professions Code). OWNER'S I Permit $AUTHORIZATION ❑ I.;as owner of the property,am exclusively contracting with TOTAL FEE �t ITO licensed contractors to.construct the pro).ect.(Section 7044, 1 HAVEAT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACT0BUSInesS'and Professions Code). .CONNECT THE ABOVE DESCRIBED FXISTING.DWELLING TO THE PUBLICSEVA9CONSTRUCTION LENDING AGENCY1 hereby affirm that there is a construction lending agency SIGNEDTHIS DAY OF ' for the performance of the work for which. this permit is OWNER O.R.. issued•(Sec. 3097, Civ. C.Y. OWNERS AGENT 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 herebyy authorize representatives of this Counfy to enter upon the pbave-mntioned pro erty for inspection purposes, Signature of Perrniftee Date SEE REVERSE FOR EXPLANATORY LANGUAGE t'here; flial I Nave a -certificate of consent :to self ; .,insurefi:cote{of Workers'Compensation Insurance, or zaAeasD :a certified copy thereof(Sec.3800,'Lob C.,) CE 908(REV..8/81) Policy No.. Compariy , APPLICAT ORS FOR PERMIT ❑ Certified copy is hereby furnished. SEWER SEWAGE DISPOSAL Certified copy is filed with the county building. inspection COUNTY Of:-LOS ANGELES BUILDING AND SAFETY de rt Date 8'7Ap1Pliconf /' 1•h0•8f`/6 FOR APPLICANT TOPILL IN CONNECTION.DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING FMANHOLIR DEPTH COMPENSATION INSURANCE ARDRESS . 7 (.This section:need not be completed if the work involved by the tocaLlTY JT )r UDR permit is for one hundred dollars($1.00)or fess.) f ( LOWER I certify that in t.h@ performance of the work for which this', CRoss sT. P . NECTI°N IFNGT0 FROM URB PA M.L.70 P.L. permit is issued, I shall. not employ any person in any.manner n t- ,so,as to become su.bjecf to the.Workers'Compensation Laws. OWNER.e.: !. t� f CO,IMP:No, JO$No MAILTRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS 3 6 d NOTICE TO APPLICANT: If, after making this Certificate of64, ,�GOIAFFIDAVIT RECORD,INSTR.NOi DATE wRIVER EASFAENT VfWy.TEL.N. Vv Exemption, you should become subject to the Workers' LEGAL Compensation provisions.of the Labor coda.you must forthwith , DESCRIPTION LOT NO. .HWY;OR St.WIDENING. comply with such provisions or this permit shall be deemed is revoked. BLOCK TRACTSTATE:.ENCROACHMENT PERMIT NO. 3' LICENSED CONTRACTORS DECLARATION NO.oF:Btoes, �{ ' 4.238 1 SITE OF LOT' NOW.ON LOT 2-1601014K Q l ... I hereby affirm that] am licensed under provisions of Chapter iuE OF 1G � /5 9 (commencing with Section 700.0) of Division 3 of the Bus!- BUILDINGS (,(� CHARGES tress and Professions Code,.and my license is in full force.and. �\ effect. CONTRACTOR19 W, CONNECTION CHARGE FEE License Number Lic:Class n° ADDRESS' REIMEURSEMENT FEE DISTRICT NO. GROUP MAP. PR SSED BY Contractor Date C(Y /'.111.}x} TEL.NO BK PO STATE. LIC. ❑ I am exempt under Sec.. of the L.A.Co.. iICENSE NO, CLASS I ► C . - • �i� L l 7 SCRIF'IION OF WORK FEE' Plumbing Code and/or Sec. of the No. FINAL HOUSESEWEgG,CONNECTINGTO DATE � VALIDA ,106 P. is B. &P. Code for the following reason SEPTIC TANKPUBLIC SEWERin ,SEEPAGE PIT OR. - � g n PITS. AND/OR DRAINFIELD . FINA . Dale .. .HOUSE SEWER CONNECTING TO � BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR OWNER-BUILDER.DECLARATION WORK TO HOUSFSEWER OVERFLOW SEEPAGE PIT,.DRAINFIELD _ �,t 7 I hereby affirm that I am exempt from the Contractor's License EXTN,CESSPOOL,DRYWELL,MANHOLE #O 6 .o o,� Law for the following reason (Secton 7031.5, Bulsness And Pro- ALTER,.REPAIR OR ABAND0[�HOUSE I fe55lOns Cade.): SEIAfER OR DISPOSAL SYSTEM ❑ I,as.owner of'the property,,or my employees with wages:as ( o o 2 7 5 0 theirsole corrlpensefjon.,will do the work and the stricfure' is not intended or offered for sale (Section 7044, Business o 0 0 5j Xj and Professions Code), OWNER'S. Permit g. 1 j,as.owner of the property,am exclusively confracting with AUTI'fI:ORIZATION TOTAL.FEE I contractors to construct the,project.(Section 7044, I HAVE AT THIS DATE A CONTRACT'WITH THE:HEREIN NAMED CONTRACTOR TO .Business,and Pro.'fessions Code), i �aoNNEGf THE ABOVE DESCRIBED EXISTING•DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS -DAY OF 19_ a far the performance of the work for which this permit is OWNERLlk- A �� OI/VNERS AGENT issued (Sec. 3097,.Civ.. C.). ADDRESS. Lender's Name. Lender's Address 1. 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 Plumbl'ng and Sewers,. and hereby authorize representatives of this County .to enter upon the above-mention d property for inspection purposes. p :Signoture of Pernn(.ttee P Date SEE REVERSE FOR EXPLANATORY LANGUAGE