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Home My Public Portal About5547-5547 1/2 SANTA ANITA AVE_Sewer__ 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 a certified copy thereof (Sec. 3800, lab C.) CE Boa(REV.B/81) APPLICATION FOR PERMIT Policy No., Company _ (P)a ❑ 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 AP LICANT TO FILL IN CONNECTION DATA CERTIFICATECOMPENSATIONOINSURANCEN FROM ORKERS' ADDRESS BUILDING y p m - STATION DEPTH (This section need not be completed if the work Involved by theMANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less. LOCALITY _ ,�" LOWER I certifyThat in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM p- CROSS ST. Y. CURE P.I, M.L.TO P.L. permit is issued, I shall not employ any erson in any nner so as to bec me su ect to the Worker am ensatio ws. "" p�-q P.c.NO. I p F' OWNER ` V?Z a R.- f;"` CO.IMP.NO. JOB NO. VIPLI'2CANT: MAIL " • ,_ TRUNK PERMIT NO.. ROAD PERMIT NODatepliCgni ADDRESS Lao �� ''6LN0710E O ff, after making 1115 CerTIf IC e Of CITY ' AFFIDAVIT WAIVER EASEMENT RECORD WSTR.NO. DATE Exemption,. you should become subject to the Workers' L. No " 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 - hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE 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 >- License Number LiC.ClassO. _ ADDRESS REIMBURSEMEN?FEE O Contractor Date DISTRICT NO. GROUP MAP POCESSED BY CITY - TEL.NO. VT BK PG 1 Z y�/ O El am exempt under Sec. -of the L.A.Co. STATE CETNSE NO. LIC, ti1"Y 6' Plumbing Code and/or Sec., of the NO. DESCRIPTION OF WORK FEE FINAL 6J LU HOUSE SEWER CONNECTING TO .i� �r"'l DATE �a_- �.- VALID TION G. PUBLIC SEWER B, & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR A r Z PITS AND/OR DRAINFIELD FINAL Date- HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM _, Signature CONNECT ADDITIONAL BLDG.ORISEWER. OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD P..L J. ^..�. I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.55, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM a P ti 0 El 1, as owner of the property,or my employees with wages as ;'F> f`) their sole compensation,will do the work and the structure is not intended or offered for sale (Section 7044, Business Permit and Professions Code). OWNER°S❑ 1,as owner of the ro ert ,am exclusive) contractin with AUTHORIZATION TOTAL FEElicensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMBusiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PCONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 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 regi�lating Plumbing and Sewers, and hereb uthorize repres tatives of this County to enter upon the ve-mentioned o 'erty f inspection p poses. Signature of Permif ee Dafe SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION I hereby affirm that 1 have a certificate of consent to self 1 insure, or a certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800, Lab C. CE 808(REV.8,81) APPLICATION FOR PERMIT Policy No._ Company 00)S ❑ 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 / STATION DEPTH COMPENSATION INSURANCE ADDRESS ? (This section need not be completed if the work involved by theFOCALITY '�- r> ' - - MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or less.) I certifythat in the performance of the work for which,.this NEAREST TYPE OF CONNECTION LENGTH FROM pe CROSS ST. Y. CURB P.L. M1.TO P.L. permit is issued, i shall not employ any Aerson in/nynnerso as to beco esu ject ro the Worker ompenss. OWNER J r�" P.C.NO. CO.IMP.NU. J08 NO. ,,> MAr. iTRUNK PERMIT NO. ROAD PERMIT NO. Date pplicant �.� � ADDRESS y t( y" /4- ` NOTICE O A PLICANT: If, after makingthis Certific e' of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE C{TY �•; TEL.No. ._ ! JJ Exemption, you should become subject to 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 ENCROACHMENT No,OF BLDGS. PERMIT NO. LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT 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 force and effect. CONTRACTOR CONNECTION CHARGE FEE } 4 License Number Lic.Class ADDRESS REIMBURSEMENT FEE O Contractor Date DISTRICT NO. GROUP MAP PROCESSED BY U STATE LIC. TEL.NO. ❑ BK PGd/I am exempt under Sec. of the L.A.C c i � O ��.� 4• _LICENSE NO. CLASS � —�j � ,�•,� VK OF WFEE ON OR Plumbing Code and/or Sec. of the NO. DESCRIPTIFINAL LU HOUSE SEWER CONNECTING TO )Je DATE VALIDATN CL (.,,(,r B. 8 P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FINAL Z PITS AND.OR DRAINFIELD Date, HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR WORK TO HOUSE SEWER OWNER-BUILDER DECLARATION =v' + r OVERFLOW SEEPAGE PIT, DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE ;, 4 0 w Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM f sf r ❑ I,as owner of the property,or my employees with wages as "7,. ,. their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business P " ❑ and Professions Code). OWNER'S Permit $property, v g TOTAL FEE "' j' f I, as owner of the am exclusive) contracting with AUTHORIZATION licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTR CTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY , 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 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 r Ulating Plumbing and Sewers, and hereb �iuthorize repr etativ of this County to enter upon the ove-mentione pert for inspection urpose Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE