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HomeMy Public PortalAbout5553-5553 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 76A6420 1� a certified copy thereof(Sec. 3800, Lab C.) C€Boa(REV.east) APPLICATION FOR PERMIT Policy No. ._.___Company ©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' BULLING COMPENSATION INSURANCE ADDRESSs STATION DEPTH (This section need not be completed if the work involved by the LOCALITY ' MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or fess.) ` LOWER I certify that in the performance of the Work for which this NEAREST TYPE TYPE OF CONNECTION LENGTH FROM permit is issued, I shall not employ any person in any manner C�OSSY. CURB P.I. M.L.TO P.L. so as to become subject to the Workers'Compensation Laws. ire P.C.NO. OWNERx ' 1, ,;t. 6 CO.IMP.NO. JOB NO. MAIL r ° '' TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant jam_ ., .m. ADDRESS4 L°. t S Certificate of s� p AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO DATE NOTICE TO APPLICANT: If, after mZn g � CI i Y ,+ "- TEL.NO. -,! 17 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.CIaSS� ADDRESS REIMBURSEMENT FEE O Contractor Date Y CITY TEL.NO. DISTRICT NO, GROUP MAP PROCESSED BY U ( STATE LIC. �" f BK _PG �/ O ElSI am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS �'� d ✓---� + i[✓ 1,( �^ Plumbing Code and/or Sec, of the NO DESCRIPTION OF WORK FEE FINALH HOUSE SEWER CONNECTING TO `� DATE y! VALIDAT N UU PUBLIC SEWER Z ""•' --� 6J B. & P. Code for the following reason SEPI IC TANK,SEEPAGE PIT OR �' PITS AND%OR DRAINFIELD FINAL i Data BY HOUSE SEWER CONNECTING TO '� ,✓i. PRIVATE DISPOSAL SYSTEM h- Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD i� ,� A I hereby affirm that I am exempt from the Contractor's License ExTN.,CEssPooL,DRvwELL,MANHOLE Law for the following reason (Secton 7031.5, BUIsness and Pro- ALTER,REPAIR OR ABANDON HOUSE s !l fessions Cade): 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). OWNERS Permit $ � ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION 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 Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWFLUNG TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY pop 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 representatives of this County to enter upon the above-mentioned property for inspection purposes. � + Signa ure of Per rttee 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 7aA642D a certified copy thereof(Sec. 3800, Lab C. CE808(REV.8/81) APPLICATION FOR PERMIT Policy No. Company Cps ❑ 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 — _ -- r` COMPENSATION INSURANCE ADDRESS y; 7 STATION DEPTH (This section need not be completed if the work involved by the r MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or less.) LOCALITY 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 shall not employ any person in any manner so as to become subject to the Work rs�Compensation.Laws. T,e '^t P. B NO. - � OWNER � '- 1 it aP� rr CO.IMP.NO. JOB NO. "), a :7K MAIL o� TRUNK PERMIT NO. ROAD PERMIT NO. Date L! l /Applicant_ , +"Y ADDRESS /-.w -� ,.,,.1 � NOTICE. TO APPLICANT: If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY F' I TEL.NO. 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. I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT 7of 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.CIg550- _ ADDRESS REIMBURSEMENT FEE O DISTRICT NO. GROUP MAP PROCESSED BY U Contractor Date _ CITY TEL.NO. ❑ 1 am exempt under Sec. of the L.A.Co. i STATE SE No. cinss /("u1 / e �' SPG /ti O DESCRIPTION OF WORK FEE U Plumbing Code and/Or Sec. Of the NO. HOUSE SEWER CONNECTING TO pgT�L G. r LU B. & P. Code for the following reason PUBLIC SEWER `� C VALIDA ONtA SEPTIC TANK,SEEPAGE PIT OR ` PITS AND/OR DRAINFtELD F L , ,� r;� Az Date HOUSE SEWER CONNECTING TOI ' PRIVATE DISPOSAL SYSTEM 'L Signature CONNECT ADDITIONAL BLDG.OR ► a '� o 6 1 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 8 6 z? `1 7 f' Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM .. m iD tm 7 ❑ I,as owner of the property,or my employees with wages as ,, 4 their sole compensation, will do the work and the structure - is not intended or offered for sale (Section 7044, Business f and Professions Code). OWNER'S Permit g ( S> ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE A— 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 Lender's Name ADDRESS Lender's Address I certify that I have read this aOplication and state that the above information is correct, I agree to comply with all County ordinances and State laws regulating Plumbing and Se'Aers, and hereby authorize representatives of this County to enter upon thelabove-m tiope4. roperty for inspection purposes, gnature 0f Per. ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE