The URL can be used to link to this page

Home My Public Portal About6039 PRIMROSE AVE_Sewer__ .* 'V A r. r n !, V1rORKERS`"COMPENSATION DECLARATION P' herAy raffirrfi thdi I%ay.e a certificate. of consent to self Insure,`or d,,certifi.catq.of Werk.ers'Compensation Insurance.,or raAa.ISD a certified copy thereof(Sec. 3800,'L4b C.). CE BOB(REV B/8.1} A la ompany C PPMCATIOM F® PERMIT POlfcy No, Certified copy is hereby furnished. SEWER o SEWAGE DISPOSAL Certified copy is.filed with.the county building.inspection COUNTY OF LOS ANGELES BUILDING AND'SAFETY Date i4PPlicant. '0J• _- FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING STATION DEPTH COMPENSATION INSURANCE •.ADDRESS I .. (This:section need not be cornpleted If the work involved by the — MANHOLE REFERENCE UPPER permit.is foi one hundred dolfors ($100).or.less.) LOCALITY_ LOWER` I certify that in the performance Of the Work for which this CROSS ST. - TYPE OF CONNECTION LENGTH P L. permit is issued, f shall not employ any person in.any manner Y. �uRB a.t,. M.L,ro P.L. so as to become subject to the.Workers'Compensation Laws. L�,'.. i Rc..No I P OWNER 0/f4 j� T...M.6 1 CO.IMP,NO. JOB NO MAIL Date Applicant ADDRESS Z'&51 I TRUNK PERMIiNO. RI0 -OAD PERMIT NO. NOTICE TO APPLICANT: If, after Makin this Certificate Of ) AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO. DATE 9 GTy 7 L NO. / Exemption, -you should become subject to the Workers` LEGAL f Compensation provisions of the Labor code,y0U must forthwith. DESCRIPTION LOT NO. "u HWY.OR ST.WIDENING comply with such p/Ovisions or this permit shall be deemed revoked. BLOCK TRACT - STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO..of docs: PERMIT NO.. SIZE OFIOT NOW ON LOT I hereby affirm that.I am licensed under,provisions of Chapter of —f7� 9 (gomm.encing with Section 7USE.000) of Division 3 of the BUS!- BUILDINGS 1.V � �. CHARGES'. ness and Professions.Code, and my (fcense is:in full force and effect. CONTRACTOR i ✓ CONNECTION CHARGE FEE License.Number Lic.Class ADDRESS REIMBURSEMENT FEE O TEL.NO. .. DISTRICT NO. GROUP MAP PR ESSED BY Contractor Date CIT., 0 �A r/ J�/0//_J� STATE —y IIC. ry �� •i ttK \✓i' d :I am exempt under Sec.. of the.L,A.CO. L'fCENSE NO 00 / . I CC 0- 44—— ' _� � �' Plumbing Code and/or See., of the NO DESCRWrION OF WORK FEE FIIVAI _� . HOUSE SEWERPUBLICSEWER To. DATE VALID BOLI _ B. &P. Code for'the following reason n S SEPTIC TANK,.SEEPAGE PIT OR TINA PITS AND/OR DPA iNFJELD Date HOUSE SEWER CONNECTING TO BY 9 PRIVATE DISPOSAL SYSTEM ! - Signature. CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO ACUSE.SEWER OVERFLOWSEEPgG1:PIT;DRAINfIELD I hereby affirm that I arrt exempt from the'Contractor s License EXTN.,CESSPOOL;URVWELL,NUINHOLE Law for the following reason (Secton 703.1.5; Buisnes;and'Pro- ALTER REPAIR OR ABANDON HOUSE fessions Code: SEWEf OR.DISPOSAL SYSTEM , ❑ I;as owner of the pioperty,or my employees with wages os their sole compensation, will do the work.and the structure L �. is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER'S Permit $: ❑ I,.as owner of the.property,am.exclusively contracting with AUTHORIZATION TOTAL FEE S' e9 licensed contractors to construct the project (Section 70.44; 1 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 2 6 ` a O A Business and•Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY '}f o G e .0 5'[( 1 hereby affirm that there is a construction lending agency: SIGNED THIS DAY OF 19� for the performance of the work for which this permit is OWNER OR 0 hh (� ( P ) OWNERS AGENT .I �N.;{ issued See. 3097, Civ. C. 6 0: Li,{� hu ADDRESS Lender's Name =s. fi.7'1.2 5 7 Lenders Address 1 certify that I have read .this application. and state that the above information is:correct. I agree to comply with all County ordinances and State laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above.mentio.ned-property for inspection purposes. f _ r Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE �' ' ' I KEN'COMPENSATION DECLARATION j 1'h fey/rfir'm-that I"'have:.l certificate of consent to self 1�t-$i ert f'catelof Workers'Corm.ensation Insurance,or. 76A6A2D i ' .In3UreC.,.. . � 6 p �CE 808(REV.B/B�1 /� [�[� /�� pt,i AA a�rtified copy ttiereDf(Sec,,.09Q0,. Lg6 C.) i lr=d�ti'C�OCAT1®tl�l FOR PE�EI ANT �to"Iicy No.. Company_ � ®s d `� -0 Certified copy is hereby furnished, SEWER - SEWAGE DISPOSAL O Certified copy is filed with.the co.uh..ty:building inspection. COUNTY OF LOS.ANGELES BUILDING AND. AFETY department. /y j� t .:....... Date. � Applicant ug a FOR.APPLICANTTO'FILL:IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS.' BUILDING L STATION DEPTH COMPENSATION INSURANCE ADDRESS (This.section(need mot be completed if the work involved by theE MANHOCE•REFERENEE UPPER permit.is for owhundred dollars($100.)or less,) LOCALITY tow NEAREST r TYPE OFL01!1NECTION IENGTNFROfN '. I certify that in the performance .of the work for which this, CROSS ST. Y, CURB P;L M.L.TO P.L. permit is issued, I shall not employ-any person in any-manner so as to become subject to the Workers'Compensofion.Laws. OWNER CO.IMP.NO. Joe o. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. ! Date • Applicant. ADDRESS S NOTICE TO APPLICANT: if, after making' this Certificate. of ��CITY TEL.NO. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR..NO.. DATE' Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code,you must forthwith ,DESCRIPTION LOT NO. y/ HWY.OR ST,WIDENING comply with such provisions or-this permit shallbe deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF:BLDGS. PERMIT NO. %a OF LOT: NOW ON LOTcf I hereby affirm that I am licensed under provisions of Chapter USE OF ;zla r/s 9 (commencing with Section 7000) of Division 3 of the BLsj.- BUijD.NGS CHARGES ness and Professions Code, and my license is in full force and effect. ; CONTRACTOR coNNEGTION CHARGE FEE � License Number Li.C..ClassADDRESS• REIMBURSEMENT O DISTRICT NO. GROUP NAP PROCESSED BY Contractor, Date � BK de o Contractor/ , CITY ; TEL.NO. .� � n / ❑ I'orn exempt under Sec. of the L.A.Co. LITCENSE�Vo.. d s CLA55 sem,:. . -. NO. DESCRIPTION OF WORK FEE Plumbing Code and/or See. .of'the FINAL HOUSE SEWER CONNECTING TO DARE VILLI® ION PUBLIC SEWER B: &.P. Code for the following reason a SEPTIC TANK,SEEPgGE PIT OR 'PITS AND/OR DRAINFIELD FINAL: , Date HOUSE SEWER'CONNECTING TO BY ' . J� s PRIVATE DISPOSAL SYSTFM ! '' `•"^�� , Signature .CONNECT ADDITIONAL.BLDG,OR OWNER-BUILDER DECLARATION , WORK TO HOUSE SEWER OVERFLOW SEEPAGE.PIT..DRAINFIELD. I hereby affirm that.I am exempt from the Contractor'.s License EXTN..,CESSPOOL,DRYWECL,MANHOLE Law for the following,reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR.OR ABANDON HOUSE. feSsiatl8 Code): .SEWER.OR DISPOSAL SY.STENt - 7� ❑ I.,as owner.of the-property,or my employees with wages as their sole compensation,will.dothe.work and the-Structure is not.intended or offered.for sole (Section 704.4, Business b? , 1 and Professions Code). OWNERS Permit $ ❑ I,as owner of the property,am exclusively contracting with ' AUTHORIZATION TOTAL FEE �y`. o o a 0.j 0 1 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRAST WITH THE HEREIN NAMED CONTRACTOR TO � / Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 0,027,50 CONSTRUCTION LENDING AGENCY 7 J�.!cT 2 9 9 r" 6 I. hereby affirm that there is a, construction lending agency SIGNED.THIS_.DAY OF 19_ 0 G OWNER OR `' for the performance of the work for which this permit is OWNERS AGENT. 0 3.25'L8 7 Issued(Sec. 3097, Civ. C.). ADDRESS Lender's Name .,• ... Lender's Address I certify that 1 have read this application and state:that the above information is correct.. I agree to comply with all County ordinances and Statelaws regulati:rig Plumbing and .Sewers, and hereby.authorize.represen'tatjye9 of this'County to enter upon the above-mentioned pro rty,fot Inspection purposes. Signature of Permittee pate SEE REVERSE FOR EXPLANATORY LANGUAGE DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1 DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY EN131NEERi BUILDING ADDRESS FOR APPLICANT TO FILL IN LOCALITY BUILDING NEAREST ADDRESS _ CROSS, LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO. c NEARESTA S CROSS ST. RECEIVED BY Ready for InsFeetian DATE ISSUED OWNER MAIL _ADDRESS USE ZONE I OCCUPANCY MAP I BK PG CITY TEL.NO. CONTRACTOR CO.IMP.NO. ADDRESS JOB.N0. CITY r� TEL.NO,A/n >L �1 TRUNK PERMIT N0. REGISTRATION NO. - - COUNTY ROAD PERMIT NO. LEGAL DESCRIPTION LOT NO. STATE ENCROACHMENT PERMIT NO. BLOCK TRACT INDUSTRIAL --------- WASTE APPROVAL SIZE OF LOT NO.OF BLDGS. NOW ON LOT CHARGES USF OF —-- BUILDINGS CONNECTION CHARGE FEE NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $ 3.50 i RECEIPT NO. DATE' I BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED WORK TO HOUSE SEWER I.00 0. ALTER QR REPAIR EXISTING I NO. DATE BY SEWER OR DISPOSAL SYSTEM 1.00 L DISCONNECT AND ABANDON SEWER AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA SEPTIC TANK,SEEPAGE PIT OR - PITS AND/OR DRAINFIELD 2.00 I STATION DEPTH CESSPOOL--DRYWELL — SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE — �oR R LOWER TYPE OF CONNECTION LENGTH FROM Y___-. CURB P.L. M.L.TO P.L. OWNERS PERMIT ; ; 1 00 AUTHORIZATION TOTAL FEE - ! HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE DWELLING TO THE PUBLIC SEWER SIGNED THIS..... ...........DAY Or _.......... ....... 19.__.. NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL I OWNERS AGENT_,_......... -....................,...._-.....-....:...._... BUILDING OR WORK SEPTIC TANK,SEEP.PIT(S) ADDRESS.-------- ___.._.______...._,......_..-------.------- AND/OR DRAINFIELD i HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL I] DRYWELL CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE LL.AL OWN- ABANDON HOUSE SEWER ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS 0 SIGNATURE SEEP.PIT(S)o CESSPOOLS } f- OF PERMI9 fEE --- k' r`'�'1° '4'"` �.� r 76A,6421) €fib 1/53