HomeMy Public PortalAbout5725-5727 RENO AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to 41f
Insure, or a certificate.of Workers'Compensation Insurance,'or 76A642D
a certified the of(Ser: 38. L CE 808(REV.B/Bt) PaPPLICATOON F®R& PERMIT
Policy No Company r Cl es
0.Certified copy is hereb furnis d. SEWER a SEWAGE DISPOSAL
Certified copy is filed w my ildi specfi.n COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. _
Datell—1-0--RIAppfico : FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EX IO FROM WO :ERS BUILDING STATION 2 DEPTH
COMPENS. NINSURANCE ADDRESS 30
(This section need not be compi.eted if the work involyUvithe NIANHOLE.REFERENCE - S
permit is:'for one hundred dollars(5100.):or less.) LocPurY AWE
N LENGTH FROM
I. certify that in the performance. of the work for which this . CROSS ST. Y. CURB P.L M.I. TO P.I.NEAREST. TYPE OF CONNECTIO
permit is issued, I shall not employ any person in any mariner P.C.NO
so as to become subject to.the Workers'Compensation Laws.: OWNER CO.IMP:No, ioB NO.
AIL TRUNK PERMIT NO. ROAD PERMIT NO.,
Date Applicant ' MADDRESS
NOTICE TO APPLICANT: If, after making This Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR..NO, DATE
9 CITY TEL.NO. Rag i
Exemption, you should become subject io the Workers' LEGAL
Compensation provisions of the Labor code,you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING
-comply with such provisions or this permit shall be deemed
revoked. BLOCK 'TRACT STATE E14CROACHMENT
LICENSED CONTRACTORS DECLARATIONSIZE OF LOT NOW ON LOT NO.OF BLDGS. PERMIT NO
.• _
I hereby affirm.That I am licensed under provisions of Chapter .USE of
9 (commencing with Section 7000) of Division. 3..of the BUsi- BUILDINGS CHARGES
ness and Professions Code, and my license is.in full forceand
effect, CONTRACTOR
CONNECTION CHARGE FEE
' � e, �
IL
License Number. Lic.Clots ADDRESS % REIMBURSEMENT FEE.
Contractor DateCtTY TEL,NO. I DISTRICT NO GROUP MAP P OCESSED BY
';�' •. n BK. PG
'STATE LIC :r /�
0 1 am.exempt Under Sec: of the L.A.Co. LICENSE NO. 1. CLASS
No. DESCRIPTION OF WORK FEE
Plumbing Code and/'or Sec.. of the FINAL AU
Is HOUSE SEWER CONNECTING TO DATE VALI ,�tl•'ION b AB. &P.-Code for the following reason PUBLIC SEWER i — h
SEPTIC TANK,.SEEPAGE PIT OR ,
PITS.AND/OR DRAtNFIELD� 'FI L o a c 0,1
�)
Date MOUSE SEWER CONNECTINGTO BY
PRIVATE DISPOSAL SYSTEM v q 215
Signature. VNNECT ADDITIONAL BLDG.OR i
OWNER-BUILDER DECLARATION WORK To HOUSE SEWER 'r
OVERFLOW SEEPAGE Pt.T,DRAINFIELD � ;o. 'o .0 � ��
I.hereby affirm that I am exempt from the Contractor's License EXTN:,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason(Sectors 7031.5, BLIiSne55 and Pro= ALTER,REPAIR.OR ABANDON U '} a—
fess-ions Code):
�G. SEWER OR DISPOSAL SYSTEM 00JL
El 1,as owner of the,property,or my employees with..wages as
their;ole compensation,will do the.work and the structure '
is not intendedor offered for sale (Section 7044, Business
and Professions Code). I OWNER'S. Permit $ JACTORTO
I,.as owner of the.property,am exclusively con.tracfing with AUTHORIZATION OTAL FEE licensed contractors to construct the project (Section,'704'4, I HAVE AT'THIS .E A C R WITH THE H EIN NAMED CONTBusiness and Professions Code). CONNECT THEA DESC BED EX TING.DWEL :HE PUBLIC SECONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agencySIGNED THIS D OF
for .the performance of the. work for which this permit is OWNER OR
issued (Sec.,3097, Cly.C.). OWNERS AGEN
lorke
Lo
Lender's
�Name ApDRE$S
Lnd Ys.A , ress
I cerIfy fhoi I have read this application and state that the
alio a infer. ation' rrect. I agree:tocomply with all.County
ord nances_ and St to ws regular Plumbing and Sewers,
an here utho i e presentat're of this•County to enter
U. n al; vp-m ned r p. y or'inspection purposes,
Signature.of P .mtttee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
�lstJ`
e3 E-669 YY•53.5 APPLICATION FOR PERMIT
&x•5
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING r
JOHN A. LAMBIE, COUNTY ENGINEER -ADDRESS _-
CASSATT D. GRIFFIN, SUP'TOF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST, ,, ��----------------
LEGAL y — �, - ---- --- -----
DESCRIPTION LOT_NO.,!' J ` OWNER y �..--- ---_--_-
,✓ ,�` -_
BLOCK 'TRACT MAIL a ✓y *+.-' ADDRESS -------
NO, OF BLDGS-.... ,,,p CITY TEL. NO.
SIZE OF LO7 PJOW ON LOT r" ' _
USE OF
BUILDINGS ,_a _ - DISTRICT,,N GROUP MAP
CONTRACTOR `� y-� - I BK
ADDRESS CONNECTION DATA
--- --- --------- -- ---�- ----- - ,� ------1--- —
_ STATION _ /- DEPTH g
CITY .SEL NG, -
MANHOLE REFERENCE 1 UPPER
-- ---- .-
STATE -- ----- ---
REGISTRATION NO, - [j COUNTY
NG. 1 DESCRIPTION OF WORK FEE -- ..--- --- - ---�-- _
r HOUSE SEWER CONNECTING TO
--- "'r- '-` -- ,.;TYPE OF CONNECTION LENGTH FROM 17 `.
P.L. M.L. TO P.L. ++'�..=
_ PU8LiC5EWER _ _ $3.50 �' ___ -.---
.I SEPTIC TANK.SEEPAGE PIT OR --- -----
j
PITS AND/OR DRAINFiELD _ $'3.00
OVERFLOW SEEPAGE PIT,DRAINFIELDj r ! P. C. NO,
EXTN.;_CESSPOO_L,DRYWELL_MANHOLE fid $2.00 CO. IMP. NO. (r JOE NO.
HOUSE SEWER CONNECTING TO `
PRIVATE_DISPOSAL_SYSTEM_ (a- $1.00 �! t. NK PERMIT NO. _ ROAD PERMIT N
_I. CONNECT ADDITIONAL BLDG.OR - _—i i STATE E-----CHMENT -.- _
WORK TO HOUSE SEWER � $1.09 PERMIT N0. _
- -..-- _ -- -- --- - _I ------------ ----- ----'
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL ""•_- "
SEWER OR DISPOSAL SYSTEM __ rl_$1.,00
WASTE APPROVAL --
.—_------- ---- - - �------ CHARGES
�P ----- - - - --------------V-- - ---. -__----_-. __----- --- --------
HAR
--� - -- CONNECTIO` GE FEE
OWNER'S PERMIT 1 00 —--- — -- --- —__ _—_---
-- - REIMB RSEMENT FEE
AUTHORIZATION TOTAL FEE ='T --
i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- __ APPROVALS I-_DATE-�_INSPECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -"
TO SHE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS._ ..DAY O t T 19 CON1IEG7 ADDITIONAL -
OR'NEP. OR >. i BUILDINt OR WORK
OWNERS AGENT '," - -- - -- ------- ---
SEPTIC TANK,SEEP,FiTISI ----- —-----.-..---
ADDRESS AND/OR DRAiNFIFLO
I HEREBY ACKN WLED E THAT I HAVE READ THIS APPLICATION CESSPOOL.L; DRYWELL❑
AND 9'FATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR.SEWER OR
PLUMBING AND SEWERS.
SEWAGE DISPOSAL SYSTEM_ -
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
II
LICENSED AS RFOGIRED BY LOS ANGELES COUNTY AND STATE OF _ABANDON COPSE SEWER i
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDLNTIAL PROPERTY. BACKFILL SE^' -_`<..t,,, —1------�j--�
S EE: aw-�i^'t�^' C.rSSPOOL t..
OF PERMITTEE
i
1OHN A. L.AMBIE, COUNTY ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PLBG. INSPECTOR
CK,
,. 4,
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