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Home My Public Portal About5555 1/2 SANTA ANITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION I hereby affirm that 1 have a certificate of consent to self insure, o" q certificate of Workers'Compensation Insurance, or 76A642D � a•ce'rfified copy thereof (Sec. 3800, Lab C.) CE soa(REV.veli APPLICATION FOR PERMIT Policy No.__ Company EPs ❑ 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 J _ FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' suILOING „ -,� y STATION DEPTH COMPENSATION INSURANCE ADDRESS :” ). ., p:.• (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 ��y- LOWER that in the performance of the work for which flus NEAREST TYPE OF CONNECTION LENGTH FROM I certify p CROSS ST. Y. CURB P L. MLI,TO P.L. permit is issued, 1 shall not employ any person in any mannc:?r _ so as to become subject to the Workers'Compensation Laws. P.c.NO. p / OWNER '.�y;;, ?"A-, ;�""" w ,,,„' :.• CO.IMP NO. JOB NO. yy++ _` ,j� t MAIL TRUNK PERMIT NO. ROAD PERMIT NO. DateKpplicant w _ ADDRESS thr Certificate of ,'�f AFFIDAVIT WAIVER EASEMENT RECORp.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making CITY .�+'>t'Y id<l"'r ,+'dr- ` TEL.NO. fir� R 1 1 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 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 'S CONNECTION CHARGE FEE License Number LIc.Class_ ADDRESS REIMBURSEMENT EEE DISTRICT NO. GROUP MAP PRO. SSED BY Contractor Date CITY TEL,NO. ❑ I am exempt under Sec.. of the L.A.Co. STATE C' `� B J xPG //S 0 p LICENSE NG. CLASS </ �s'�. NO Plumbing Code and/or Sec. of the . DESCRIPTION OF WORK FEE FINAL �f ,ryry HOUSE SEWER CONNECTING TO 's" > DATE ,d° -Cs-,. '" VA PUBLIC SEWER LID . ION 7 „ B. & P. Code for the following reason FIN ,f Z SEPTIC TANK,SEEPAGE PIT OR Date PITS AND/OR DRAINHELD L.. HOUSE SEWER CONNECTING TG BY x pR PRIVATE DISPOSAL SYSTEM 9 ip Signature__ CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINF;ELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWEtL,MANHOLE Low for the following reason (Secton 7031.55, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fes ions Cade): SEWER OR DISPOSAL SYSTEM ! r; ❑i,1,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 (pnd Professions Code)- OWNER'S Permit JCONTRACTOR I,',as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEElicensed contractors to Construct the project (Section 7044, 1 HAVE ,AT'THIS DATE A CONTRACT WITH THE HEREIBusiness and Professmns Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TCONSTRUCTION LENDING AGENCY ,Ihereby 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 regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. 1 : s Signature ;f P mittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE -eD ,.aLT308(REV 8/81) App��LOC�I�QU0OO H FOR ISpC�L°hAV 97 gab CuTa^ce,aT a -oI.r,,ny_ SLSC7nER o SEWAGE DOSPOSAL ereby furnished. J COUNTY OF LOS ANGELES BUILDING AND SAFETY Y is filed with the county buil,pectio^ CONNECTION DATA FOR APPLICANT TO FILL IN Applicant BUILDING } STATION DEPTH eTIFICATE OF EXEMPTION FROM ADDRESS �. � Air �P' UPPER COMPENSATION INSUR M WORKER r MANHOLE REFERENCE LOWER action need not be c ANCE LOCALITY �it= TYPE OF CONNECTION LENGTH FROM .It is for one h ompleted if the work invoi.; NEAREST undred dollars ($100 CROSS sr Y. cues P L M.L.TO PA If ertify that in the performance )or less.) PC.NO ..rmit is issued, I shall net nO to of the work for vv 11 —�s+i�- CO IMP.NO. JOB NO as to become subject t OWNER a �.Qvd✓1 employ any person in nr I O'he Workers MAIL TRUNK PERMIT NO. ROAD PERMIT NO Date t Compensnt ADDRESS ?/ C�% +�ci�f%J NOTICE MAppli_ont i ate of ��1` q AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO DATE O APPLICANT• If c1Tv,� (r'dam' '` TEL.NO. 9(/i Exemption, ,ou sh,uld after ^'-king th• 'Yorkers' LEGAL Compensation prov, oul become subject 16 deemed DESCRIPTION LOT NO. HWY OR ST.WIDENING comply Wlth such piovisionshe Lobar Permit y b deemed BLOCK TRACT STATE ENCROACHMENT revoked. Or this PERMIT NO permit NO.OF BLDGS LICENSEE CONTRACTORS vN SIZE OF LOT NOW ON LOT I hereby-ffirm thotI- ACTORS DECL•tons of Chapter USE OF win m licensed underin 3 of the BUsi- BUILDINGS CHARGES ness nd ProfesstO,;Co cl Oond000) of Is in full force and effect. CONTRACTOR ✓ CONNECTION CHARGE FEE my lic UCense Numberss ADDRESS r1 REIMBURSEMENT FEE 011tracta,--LIC DISTRICT NO GROUP MAP PROCESSF�BY CITY TEL.NO ` 1 l ❑ I n.zrem } —r of the L.A.Co. STATE LIC 151. �`r1 f 0-t" p Jncier Sec._ LICENSE NO. CLASS 51. o' �' NO. DESCRIPTION OF WORK FEE VALIDAYIO F',rtbing Cad-and/or So of the FINAL C ��'i HOUSE SEWER CONNECTING TO DATE•- /.• B, a p PUBLIC SEWER / Gl C de for the fi„+ving reason SEPTIC TANK SEEPAGE PIT OR PI I PITS AND'OR DRAINFIELD 1.._ -----Date HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM ignoure CONNECT ADDITIONAL BLDG OR r OWNEFBUILDER DECLARATION WORK TO HOUSE SEWER t hE OVERFLOW SEEPAGE PIT,DRAINFIELD L-WAY atirm that I q,1 exempt from the Contractor's License EXTN,CESSPOOL,'PIT 'L,MANHOLE Fassio he allowing rbson(Secton 7031.5, Buisness and Pro- SEWER RE DISPOSALORBS SYSTEM HOUSE 'own:-of the Io tn`'sole� P t-rty,or my employees with wages as is ni. ampensatl- will do the work and the structure and Interled or olfeed for sale (Section 7044, Business Permit S 1 T 7fes.anns Code). OWNERS I, °S Goer r the ro erl, Al1TIiORIZATION TOTAL FEE .� license P P am exclusively contracting with : contiactors Ir, col%truct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO lusine;and F-ofessions C(de), CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LLVDING AGENCY b7 offin tho' there IS a;onstruction lending agency SIGNED THIS DAY OF 19_ Sec. 307, of the wol` far which this permit IS OWNEROWNERS AGENT n, CIv. C.). Name ADDRESS •ddress at I h'Je read this application and state that the rnat'Orl s correct. I agree to comply with all County end Stoe low: regulating Plumbing and Sewers, outhori;e representatives of this County to enter vo-rnenioned,property for inspection purposes. V "-1rml1tee Date SEE REVERSE FOR EXPLANATORY LA;, sE