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Home My Public Portal About5545-5545 1/2 SANTA ANITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION I he�rebK affirm that I have a certificate of consent to self insure, or a certificate of',Norkers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800, Lab C.) CE BOB(REV 8/81) APPLICATION FOR PERMIT Policy No—`—Company _____ s r ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment. Date_-Applicant_.__ FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS` BUILDINGJ SranoN DEPTH COMPENSATION INSURANCE ADDRESS_l (This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY - � -T LOWER I certify that in the performance Of the Work for which this NEAREST TYPE OF CONNECTION LENGTH FROM CROSS ST, Y, CURB P.L. M.L.TO P.L. permit is issued, I s ll not employ any person i6theorkers' ner so as to be me su ject to the Workers'Compens. OWNER `._ f- � { � �� F ., P c NO /�s ,,. ` CO.IMP.NO. !OB NO. ". /`` _ MAIL _S ��,;`V za TRUNK PERMIT NO. ROAD PERMIT NO. Date "OA pplicant 4-+ ADDRESS l �, NOTICANT: If, after making this Of CIT � AFFIDAVIT WAIVER EASEMENT RECORD:INSTR,NO. DATE Exemption, you should become subject to Y ' TL, rLo. 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 ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO,OF BLDGS. PERMIT NO. I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTuSEOF 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 Lic.Class_ /` o' ADDRESS REIMBURSEMENT FEE O Date Contractor DISTRICT NO. GROUP MAP PROCESSED BY CITY TEL.NO PIG Z El am exempt under Sec, of the L.A.Co. STATE C �� BKS O LICENSE NO. CLASS F`+� tl I�� U Plumbing Code and/or Sec, of the NoDESCRIPTION OF WORK FEE- FINAL HOUSE SEWER CONNECTING TO 7 p DATE �' VALIDATI a B. & P. Code for the following reason PUBLIC SEWER ( { — H SEPTIC TANK,SEEPAGE PIT OR FINAL Z PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY ' PRIVATE DISPOSAL SYSTEM ' 'f„- Signature O ° �' r' g CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ► 4 I hereby affirm that I am exempt from the Contractor's LicenseEO ERFLOW SEEP GE PIT, MANHOLEtEL p u) Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 7 fessions Code. 7A): SEWER OR DISPOSAL SYSTEM ( f ❑ I,as owner of the property,or my employees with wages as 75`.-J.77 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code), OWNER'S Permit g C/� F0 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE r licensed contractors to Construct the project (Section 7044, 1 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, CONSTRUCTION LENDING AGENCY , 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 OR issued (Sec. 3097, Civ. C.). 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 hereby authorize repro ntatives of this County to enter upon the ve-mentione pro ori t r inspection urpose Si nature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE I WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D ,o c—Pritifiekd copy thereof (Sec. 3800, Lab C.) CE808(REV B,BI) APPLICATION FOR PERMIT Policy No., Company_ Gs ❑ 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 Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING �i" ( n COMPENSATION INSURANCE ADDRESS ' d STATION DEPTH (This section need not be completed if the work involved by the y "c_ e.y MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or less.) LOCALITY l LOWER I certifythat in the NEAREST TYPE OF CONNECTION LENGTH FROM performance of the work far whi h this CROSS ST, Y. CURB P.L. M.L TO P1_ permit is issued, I shall not employ an person in any tanner so as to Ime "bject to the Worker �'COmpensati aws. ,a OWNER .+r , ;} y f` CO.IMP.NO. Job No. MAIL Date AppllCpn4 Jae ADDRESS { m - r TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE 'TO A PLICANT: If, After making this Certifi ate Of e E AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE 9 CITY r `7> .y EL NO- Exemption, you should become subject to the Yorkers' LEGAL 5774 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 ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.SIZE of LOT Now ON LOT 1 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 force and effect. CONTRACTOR CONNECTION CHARGE FEE e>- CL License Number Lit,Class— ADDRESS REIMBURSEMENT FEE O Contractor Date ,.,,..r'- , DISTRICT NO. GROUP MAP PROC/E�JSEE BY CITY TEL.NO. }y TBK PG ///l Z STATE UC- (�/dl LICENSE NO. CLASS r % / ❑ I am exempt under Sec. of the L.A.Co. 0 NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec, of the FINALW DATE HOUSE SEWER CONNECTING TO i / � PUBLIC SEWER (. - C✓ VAUDATI H B. & P. Code for the following reason_ SEPTIC TANK,SEEPAGE PIT OR �f Z PITS AND'OR DRAINFIFLD FINAL Date HOUSE SEWER CONNECTING TO. BY PRNATF DISPOSAL SYSTEM �� ..' '.✓' 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,DRYWEI,MANHOLE Law for the following reason (Secton 7031.5, BUisness and Pro- Ai TER,REPAIR OR ABANDON HOUSE fessions.Code): SEWER OR DISPOSAL SYSTEM .ww; S� E,[y A ❑ I,as owner of the property,or my employees with wages as $ their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business E r and Professions Code). OWNERS Permit $ ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE �R licensed Contractors to Construct the project (Section 7044, 1 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. CONSTRUCTION LENDING AGENCY , 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 OR issued (Sec. 3097, Civ. C.). 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 re. uI ting Plumbing and Sewers, and hereby Phorize repro tat"" of this County to enter upon the owe-mentione perty fo 'nspection rpose . Si ature pf Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE