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HomeMy Public PortalAbout5549-5549 1/2 SANTA ANITA AVE_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure,sir a certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800, Lab C. CE808(REV.8%81) 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 / A- COMPENSATION INSURANCE ADDREss STATION DEPTH (This section need not be completed if the work involved by the �< UPPER permit is for one hundred dollars ($100)or less.) LOCALITY F� �s' 'r,, MANHOLE REFERENCE LOWER I certifythat in the performance 4f the work for Which this NEAREST TYPE OF CONNECTION LENGTH FROM e p CROSS ST. Y, CURB P.L M.L.TO P.L. permit is issued, I shall not employ any person in any manner so to CO Date tObecome •rsubjecte Workers' COmp., soton,. w5. DREOW SS 1 ,.f���k't�� � Gc �r; :_"MAIL TRU KPERMIT NO. ROAD PERMIT NO. I -- Applicant NOTICE TO APPLICANT: If, after makingthi Certificate of ' r, ( s� AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO. DATE CITY ;.. � TEL.NO. �'R,..,»� ,.. ,w*I .:: .�f . 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 LICENSED CONTRACTORS DECLARATION NO.of LOT PERMIT No, 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 s CONNECTIONS CHARGE FEE 9„ @. License Number Lic.Class— - ADDRESSZLI-ff - REIMBURSEMENT FEE O DISTRICT NO GROUP MAP PR ESSED BY V Contractor.. Date CITY q TEi.NO. _ STATE LIC.❑ 0 1 am exempt under Sec. of the L.A.Co. LICENSE NO.. CLASS Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL ✓' HOUSE SEWER CONNECTING TO a p") DATE VALIDWTION B. & P. Code for the following reason PUBLIC SEWER s IJ ul ul SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE 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,DRYWELL,MANHOLE Law for the following reason (Secton 703.1.5, Buisness 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 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit $ (e ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE ' f 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. t - •- 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 p p" OWNERS AGENT _ issued (Sec. 3097, Civ, C.)- 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 representatives of this County to enter upon the.,:above-rrLOntionedaproperty for inspection purposes. 01 Signature Of Per Ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE 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 808(REV 8181) APPLICATION FOR PERMIT Policy No. Company ©s ❑ Certified copy is hereby furnished. '', SEWED - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspections t; COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BuaDING STATION DEPTH COMPENSATION INSURANCEu ADDRESS(This section need not be completed if the lb 'the' ,mom' UPPER petee work involved Y LOCALITY .r"t (,� - 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 e p CROSS ST. Y CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any rson in an Manner _ so as to bec me su ect to the Worker Com ensat' n `ws. P C.NO, p OWNER ' ,e- L �� / CO.IMP.NO. !OB NO. �.. - MAIL Date - pplicant DDRESS x' t 1 t w TRUNK PERMIT NO ROAD PERMIT NO. .-- - ._ _ y..z AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certif' ate of CIT +Y + Al.No. s :" " 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 LICENSED CONTRACTORS DECLARATION NO.OF BLDGS, PERMIT NO. 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 >- License Number Lic.Class_ ADDRESS d F. �_,. REIMBURSEMENT FEE Q Contractor Date DISTRICT NO. GROUP MAP PROLE ED BY V CITY TEL,NO. B �( K � PG Z ❑ 1 am exempt under Sec. of the L.A.Co. S ATE NC. Gass ✓`9 O � ' U Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL VALIDATI LU HOUSE SEWER CONNECTING TO ��" / DATE �!-^ c... 7 PUBLIC SEWER / 4J �� AL B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR Cr Z PITS AND/OR DRAINFIELD FINAL ' Z Date HOUSE SEWER CONNECTING TO BY ) r f f yt PRIVATE DISPOSAL SYSTEM ^S.r Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I om exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness 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 their sole compensation, will do the work and the structure is not intended or offered for sole (Section 7044, Business and Professions Code). OWNER'S Permit $ / 7 AUTHORIZATION f' 'J` ❑ I,as owner of the property,am exclusively contracting with TOTAL FEE licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and ProfeSSlon$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 14_ ► P ra ti .I for the performance of the work for which this permit is OWNER OR ` ssued (Sec. 3097, Civ. C.). OWNERS AGENT r-, r, ADDRESS Lender's Name , !� v 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%gulating Plumbing and Sewers, and hereby authorize repr entatives Qf this County to enter upon the ve-mention roperty f f inspection rpos signature of Permits_ Date SEE REVERSE FOR EXPLANATORY LANGUAGE