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HomeMy Public PortalAbout5615 SANTA ANITA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION ?0-005?GPW 6t89 I-hereby oflirm that I have o certificate of consent to self Insure,, cr.a certificate of Workers'Compensation Insurance, or 7GA642D a ceryfj d «>py thereof (,e 3B(}0, L , ,� � APPLICATION FOR PERMIT r Poiicy �ornpanY- ��. 4aatcf-! L✓ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL 1 Certifiedcopy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment. 1?�B �I DatetA 1- q!L Apphizant �^' 1. rt f FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' au!LD!Nc � �� "b 5,,710N -DEPTH COMPENSATION INSURANCE ADDSE'SS (This section need not be completed if the work involved by me , nna,r H L€REFERENCE UPPER permit is for one hundred dollars ($1003',or less.) LOCALITY �W R + TYPE,OF CONNECTION certify that in the performance of the work for which this NEAREST r LENGTH PFROM L g Y p CROSS 9T. � `. "'iY CURE P L M L TCPL permit is Issued, I shall not employ any person In any mariner LEGAL PC, NO 5a a5.t0 became subject PG the Workers' Compensation Laws. DESCRIPTION L07 N:;. g CO IMP NO JOB NO Date. ApplicantBLOCK J.11 TRACT (�. ,. TRUNK PERMIT NO ROAD PERMIT NO ASSESSOR. AFFDAVLT , WAIVER EASEMENT RECORD INSTR NO DATE NOTICE TO APPLICANT If, after making this Certificate of IMAP E11OO PAGE PARCEL Exemption, you should become subject to the Workers' No.Cr Et DGS Compensation provisions of the Labor code, you must forthwith SIZE OF LOT Z NO OF 'Wil OR ST WIDENING, comply with such provisions or this permit shall be deemed USE crF revoked. EiU!I_DINGS A?E ENCROACHMENT F:M:IT rJC LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter OWNER 4 (commencing with Section 7000; of Division 3 of the Busi- ?AIL 1 r. . CHARGESA.DD'R ESS c7�' ness and Professions Cade, and m}7 license is in full force and " feet. CITY �pt(h..g,�Op ry*(�, TE!_.NO.Ct " 4b aeL� CONNECTION CHARGE FEE r ^" q icense Numberx -1 Lic.Class_. REiMEUPSEMENT FEE CONTRACTOR -� - DISTRICT NO GROUP MAP PROCESSED By C,OnfraC Cr`'-ti ✓�!A)L i GREale { ! l T--- 1— ADD' r Iexempt _ aK PG L J am exem t under Sec._ of the L.A.Ca. a s r c yy a(j i p CITY W' ilk TEL NO. (o C,$e !'` , O Plumbing Cade and/or Sec. of the STATE �, ICS c—I- FINAL LICENSE NO. )?l CLASS DATE f VALIDATION z B. & P Code for the follower,g reason NO. DESCRIPTION OF WORK FEE O gg HOUSE SEWER CDNNEC IVG TO �--qq FINAL c. Date B PUB.iC SEWIFR '" Z.'t.3 BY Lu oEPTIC TANK SEEPAGE nil OR `uit,�"t Signature ',IS AND OR DRAINFIE LD CL HOJ E',EWER CONNECT NG?C OWNER-BUILDER DECLARATION R vATE oisPO AL S STFM z I hereby affirm that I am exempt from the Contractor's License CONNECT AGDITIONAt BtDC� OR r Law for the fallowing reason (Becton 7031.5, Buisness and Pro- WORK TO HC.LSF SEWhR OvEPFLOW SEEPAGE PIT DRA NFtELD fe5sions Cade}: Ex"N CES POOL..DRYWELL MANHOLE .. J I, as owner of the property,or my employees with wages as ALTER REPAIR OR ABANDCN HCusE their sole compensation, will de the work and the structure aE IdER OR D SPOSAL SYSTEM is not intended or offered for role (Section 7044, Business i and Professions Code). J I, as owner of the property, ant exclusively contracting with ..., licensed contractors to construct the project (Section 7044, OWNER'S Permit $ f Business and Professions Code). AUTHORIZATION TOTAL FEE } I ab i .. CONSTRUCTION LENDING AGENCY I HAvE AT THIS rA r A L CN a ' +t IteRr rNjAWONTRACTOR rC hereby affirm that there is a construction lending agency CONN(T THE A60,E„FSI-PIBEL EX1S7.Ni )4EPONG THF PUBIC SEWF_R •. for the performance of the work for which this permit is ss`ued (Sec, 3097, Civ C-l. SIGND1t1i DAYOF q� ,)WNER OR Lender's Nar71e_ __ OW N'cRS AGEN1 lender's Address—-------- ADDRESS _... certify that I have rend this.opphcatiori and State that the above information Is Correct. I agree to comply with all CGc.anty €i ordinances and State laws regu!otina Plumbing and Sewers, t -nd hereby authorize representatives of this County to enter F Lthe above-mentioned property for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION " ! hereby affirm that I have a certificate of consent to self 20-0051 DPW 6189 insure, ora certificate of Workers' Compensation Insurance, or 76A642D a c �6 c thereof {Sec. 380-0,——Lob Pomany APPLICATION FOR ' p'EpMI i SEWER ' SEWAGE DISPOSAL Certified copy is hereby furnished. Certified copy ,s filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY` department�y �, Date 1C.-"� .'`� Applicant___._ �'4✓ WORKERS'COMPENSATION DECLARATION 20:0051 DPW EilBB 11 I hereby affirm +hat I have a certificate of consent to self NNN insure, or a certifecate of Workers'Compensation Insurance, or 76.A6420 cs cer�Ified there f 'Sec 3800, to �, _ P6 4-1 y Na. mpariy.— - __ fa .. APPLICATION FOR PERMIT Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection JI COUNTY OF LOS ANGELES BUILDING AND SAFETY departm t. 5 - DateApplicant �'� FOR APPLICANT TO FILL IN CONNECTION DATA l! CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING g ;.ATION EPTH COMPENSATION INSURANCE ADDRESS � � (This section need not be completed If the work involved by theF .tiANHOtE REFERENCE UPPER yh perm+t is for one hundred dollars ($100) or less ) LOCALITY L oweR %,. NFARES'1" � P. TYPE OF CONNECTION Certif that In the erformance of the work for which this AA M L TO FROM Y p CROSS S1 Ff 57 CURE P! kt i TOP L permit is issued, l shall not empioy any person in any manner LEGAL P C. NG So as t0 become subject to the 'Workers' Compensation Lows- DESOHSPTIGN LOT NO. CO !MP NO 1:7 P.NO r BLOCK TRACT �(,ar TRUNK PERMIT NO - ROAD PERMIT N6 Date _Applicant_ NOTICE T© APPLICANT: If, after rT1akM this Certificate of ASSESSOR AH`10AVIT WAIVER EASEMENT RECORD INETR NO L7ATE g MAP BOOK PAGE PARCEL Exemption, you should become subject to the Workers` NO of BLDti>. Compensation provisions of the Labor code, you must forthwith SIZE OF Lor NOW ON I o' HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF � revoked. BUILDINGS �" "� S'A?E ENCROACHMENT PERNrIT NO LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter OWNER } _ 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL �i ,p��*g t �' ess and Prof esions Code, and my license is In full Force and ADDRESS l .. 00 � � cHARGEs :effect ��. CITY q A�q TEL.NO CONNECTION CHARGE FEE ;cense Number __ � Lic Class 6^�.;a a p p ��p` 1,0 Re MBURS€MENT FEE _.___._ (;ON?RACTr.JFt �"'4"� /Cly T rcwtLC d DISTRICT NO GROUP MAP PROCESSED By ntraC.ar Fd" F Date 1' ADDRESS f '° � BK PC, J I am exempt under Sec. — of the L.A.Co. / a rIII,, e�^s(� 0-CPTY ! P� t TEL N d' / l-. " .....P. r Q Plumbing Code and/or Sec. of the STATE /3 ... F,NAL U LICENSE NCL .;: �$ , _. c.t.Ass " - ;,ATE VALIDATION_ Z B. &P. Code for the following reason NO. DESCRIPTION OF WORK FEE td' HOt.5F SEWER CONNECTING TO F",AL .l - °`• () Dole _ PCB 44 B+5EV eR SEPT C ,ANKEEPAGE PIT OR Signature, - P S AND UR DPA NFIE D CL HOUSE SEWEC,R ONNECTINTCr C OWNER-BUILDER DECLARATION PRIVATE DISPOSAL w-sTEM ® '� hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR. Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SFNlER OVERFLOW !EPA..E PIT DkAINFIELb fecSians Cade): EXTN £SSPOO_ DRt Wfu MANHOLE 3, j JI ALTER REPAIR JR ABANDON HOUSE - z .. 1, as Owner of the property, or my employees with wagers as ,E4vtR CR L,ISvOR ABAL SYSTEMDO their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business "rd Professions Cade). d} I as owner of the property orn exclusively contracting with L licensed contractors to construct 'he pro!ec.t (Section 7044, OWNER'S Permit s I l Business and Profess ons Code). AUTHORIZATION I TOTAL FEE 171 1 i CONSTRUCTION LENDING AGENCY HAVE AT THIS LATE A C.,INTRACT Wi H THE HEREIN NAMEC .TkACTCR tt' nereby offirm that there is a construction lending agency CONNECT THE ABCvE DES P;BE1 Ex,STiNG D'AEs,ING TO THE PUE,C SEWER or the performance of the work for which this permit is .sued(Sec. 3097, Civ. C.). SIGNED THIS DAY Ot_ 19_. ­4 1. enders Name---------- , ON NFRj AG€rJT, •-• -m•. ADURf95 tinder's Address certify that I hove read this application and state that the information is correct, 1 agree to comply with all County ndtnances and State laws regulating Plumbing and Sewers; and hereby avtherize representatives of this County to enter upon the above-mentioned property for Inspection purposes. ye ti TI 4 Si nature of PPrrrliftee fate SEE REVERSE FOR EXPLANATORY LANGUAGE . WORKERS' COMPENSATION DECLARATION 20-0051 DPW 6/89 hereby affirm that I have 0 certificate of consent to self 76A6420 insure, ora cerr,f,cote of Workers' Compensation Insurance, or T f d a c 14 TCO tt:!�f (Sec, 3800 lab a APPLICATION FOR PERMIT Comp ny Pal C7, 1o&k__T_-� 1-1 Certified copy is hereby furnished, SEWER - SEWAGE DISPOSAL Fil Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING.AND SAFETY department. 0 1. Date"_,Al2 ,C ,- -telt- V_ V'1jApphcanI Ck— FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF: EXEMPTION FROM WORKERS' BUILDING D — / JWIT 51 ATKN DIEPT ADDRESS H COMPENSATION INSURANCE TfPF (Th!F,section need not be completed if the work involved by theMANHOLE RFQRFNCA UPPER CjJ34 'LOWER permit is for one hundred dollars ($100)or less LOCALITY NEARES1Ir TYPECY CONNIECT,ON LENGTH FROM I certify that in We performance of the work for which this CROSS,ST -ru L—L—S CURB P L MIL TOP L permit is Issued, I shall not employ any person in any manner LEGAL P C NO so as to become subject to the Workers'Compensation Laws DESCRIPPON OT NO, C0 IMP NO JOB NO D Applicant BLOCK TRACT TRUNK PERM'T NO ROAD PERMIT NO _= EASEMENT RECORD INSTR NO DATE ASSESSOR APFID,� 'T NOTICE 'APPtICANT: If, after making This Certificate of MAF'BOCK PACE PARCEL Exemption, you should become subject to the Workers No.OF BLDCis Cornpenscitton provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HVy OR ST WOFNING comply with such provisions or This permit shall be deemed USE OF A revoked. LICENSED CONTRACTORS DECLARATION BUILDINGS STATE.PERMIT NO ENCROACHMENT 1-- I hereby affirm that I amlicensed under provisions of Chapter O.NEII4,\ CL C,616b�tlf MAIL 9 (commencing with Section 7000) of Division 3 of the Busi- ADDRESS CHARGES ne,s and Professions Code, and rnV license is in full force and effect ry SIT, TELNO CONNECTION-ON CHARGE FEE - C , - NJ Ly,,L, License Number :�Iic,Class, CON I RAC OR REIMBURSEMENT FEE L DISTRICT NO GROUP MAP PROCESSED By PG ADD��F 8 K I am exempt under Sec. of the L.A, Co. _> TEL.NO. t 1Y 6_10� 0 Plumbing Code and"or Sec. of The STATE LLC;. I NAL V 41 Q CLASS C:ATE LICENSE NO. e� VALIDATION z B. & P Code for the following reason NO. 1 DESCRIPTION OF WORK FEE HOUSE SEWER CONNEC"ING TO ^7 -,AL Date PUBLic SEWER B, SEPT TANK SEEPAGE PTT R 1," ' LU Signature-- P,TS� OAl ,X OR DPAINFiELD OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM z I hereby affirm that I am exempt from the CentrOCtor'S License CONNECT ADDITIONAL FILLIC, OR Low for the following reason (Sectcn 7031.5, Buisness and Pro- WORK 10 HOUSE SEWER OvEiRF,Ow SEEPAGE PIT DRAINI"ELD fessions Code): EXTI, FSSPOCL DRYWELL.MANHOLE I AI TER REPAIR(DR ABANDON HOI,SE T �r my employees with wages as j 1, as owner of the property, a SEWER OR.DISPOSAL SYSTEM their sole compensation, will do The work and the strjicture is not intencled or offered for sole iSection 7044, Business and Professions Code). owner of the property,o"i exclusively contracting with Permit $ 7 1 OWNER'S licensed cOntracfOrS to Construct the project (Section 7044, Business and PrOfesSior.S Code). AUTHORIZATION D TOTAL FEE CONSTRUCTION LENDING AGENCY HAVE THIS DATEA CONTRACT Nil H HE HEREIN ANAMED"C�01N3FAC13P �1, TO T"P SEWER W U )ereby affirm that there. is a construction lending agency CONNECT THE ABOVE DESCP,BF0 EXI`�TIN_,D El WE DW TO THE PUB0(_SE R For the performance of the work for which this permit is 9 slued (Sec 3097, Civ. C SIGNED THIS DAY OF _19— �)WNER 01',' ender's Name----_ 04NERS AGENT_ tinder's Address_ ADOREsS ---- certify !hat' I have read this application and state that the .1bove information is correct. I agree, ro comply with oil County rdinarCeS and State laws regulating Plumbing and Sewers, and hereby authorize rPpre5entcjtjveS of this County to enter upOn the above-mentioned property for inSpeOlOn. purposes ( 13 S,gnoti,ire Of PeFrnttlee Date SEE REVERSE FOR EXPLANATORY LANGUAGE