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Home My Public Portal About5540-5542-5544 SULTANA AVE_Sewer__ WORKERS COMPENSATION DECLARATION r I hereby. affirm that 1 hove a certificate of consent to seN 200051 DPW N88 Insure or a certificate of Workers Compensation Insurance or I6A6E2D a certified ropy thereof Sea 3800 Lob C , 11 APPLICATION FOR PERMIT Policy No�a� mpany S374LE r_-Z ❑ Certified ropy is hereby furnished - T _ SEWER - SEWAGE DISPOSAL ' ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment ° ' Dote L.I '?; Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS l COMPENSATION INSURANCE ADpgESS V.2 �yy.� STA11pN /,�� 3 OFPTH This section need not be completed If the work involved b the utroEv ( l y LOCALITY 4 AMNHIIXE REFERENCE R permit Is for one hundred dollars ($100)or less ) ¢NGTH FROM NEAREST IVF[ f NN certify that In the performance of the work for which this GRoss ST r'�fw�• v CUR PL MI tool permit Is issued I shall not employ any person in'ony manner LEGAL PG tip a so as to become subject to the Workers Compensation Laws DESCRIPTION LOT NO CO IASP NO Hie NO Date Apphcont BLOCK TRACT TRU"PERMIT NO ROAD PERMIT W NOTICE TO APPLICANT If after makin this Certificate of ASSESSOR AFFIDAVIT WMVER EASEMENT HCORO WSrR NO DATE 9 MAP BOOK PAGE PARCEL Exemption you should, become subject to the Workers NO OF BLOCS Compensation provisions of the Labor code you must forthwith WE OF LOT NOW ON LOT HWY ORST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked I I BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT NO I herebyaffirm shot I am licensed under OWNER provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bust MAIL CHARGES , mess and Professions Code and my license Is In full force and ADDRESS effect a CITY TEL NO CONNECTON CHARGE FEE License Number S_Z.S rr-Tl Lic Class REIMBURSEMENT FEE �. CgNTMCTOR DISTRICT NO GROUP MAP PROCFSSfp By Contractor E AAMi�- - RIC Date 7)i f L .A ADDRESS' ZG d�E.l it 8[ PG ❑ I am exempt under Sec of the L A Cof�11 CITU �j_ TEL NO 7 illy ��Z "`�e ;3 Plumbing Code and/or Sec ofthe STATE FINAL LICENSE NO 2.S( cLnss G Z DATE VALIDATION B 8 P Code for the following reason NO 0MRIPTIDN OF WORK FEC — t 0 HOUSE SEWERCONNECTING TO FINAL Date PUBLIC SEWER BY V lJ / PITS ASEPm< D O DRANFI PITLD OR a $Ignalure �7 Hrs AND OR pIRAGE IO N OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING TO ► _ PRIVATE DISPOSAL SYSTEM r. 1 hereby affirm that I am exempt from the Contractors License CONNECT AOCnIGI BLDG OR it'D Low for the following reason (Secton 7031 5 Business and Pro WORN TO HOUSE SEWER 4. fessons Code) OVERFLOW SEEPAGE PITGRAINFIELD Alii " EXTN CESSPOOL DRVWELL MANHOLE 'T ALTER REPAIR OR ABANDON HOUSE E, C" ❑ I their owner of the property or my heemployees endue wages re SEWER OR DISPOSAL SYSTEM 3307 6'.5.J their sole compensation w111 do the work and the structure is not intended or offered for sale (Section 7044 Business 1 FTENS and Professions Code) TOTAL66 - 5-3 El as owner of the property am exclusively contracting with OWNERS Permit s licensed contractors to construct the project (Section 7044 - iHEIHR �(P ? Business and Professions Code) AUTHORIZATION TOTAL FEE w/O �' (HANGS . .CID CONSTRUCTION TENDING AGENCY HAVE Al THIS DATE A CONTRACT WITH THE HEREIN NAMED coarRACtoa TO , I hereby affirm that there Is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER for the performance of the work for which this permit is Issued (Sec 3097 Clv C ) SIGNEDTHIS / DAY OF 19 )lrlly-I_ht'Ihi 7,ii/�yt Lender s Name (rvr4R J'J IV lV JJ 1 OVINERS ArCJI c Lender s Address ADDRESS ��.2 2t L Ji d.. "r:19 L AN 9.4: 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 Stole jaws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter upon the above mentioned property for Inspection purposes , L SignovI Permits to SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS COMPENSATION DECLARATION 41 p 0051 DPW GM hereby affirm that I hove a certificate of consent to self Insure or a certificate of Workers Compensation Insurance or 76AWD Pcertified�° III, n800� ;at o po1 APPLICATION FOR PERMIT ❑ Certified copy i3 hereby furnished " - SEWER - SEWAGE DISPOSAL s a�Cernfied copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDINGiAND SAFETY / depanment _ Dare 7�/ 9 ppl'ca. /D FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF E MPTION F M WORKE➢ BUILDING COMPENSATION INSURANCE ADDRESS ST�/ STATION f 43 DEPTH (This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE �' 70 R permit is for one hundred dollars (5100)or les ) rvPE Of COFINECt OiVK I certify that In the NEAREST ,p 1{�E•� M I TO P y performance of the work for which this NEAREST, Zp- r GJFSt+��Ij�l vt Mf TO FR permit is issued I shall not employ any person in any manner LEGAL - PC NO so as to become subject to the Workers Compensation Laws DESCNPOON LOT tw CO IMP No son NO PA K TRACT TRUNK PERMIT NO • ROAD PERMIT NO ` Dote Applicant NOTICE TO APPLICANT If after makingthis CerhhcGte of SSOR _ AFFIDAVIT WANES EASEMENT RECORD INSTR NO 041E BOON PAGE PARCEL Exemption you should become subject o the Workers NO OF BLOCS Compensation provisions of the labor code you must forthwith OF LOT NOW ON LOT Hwr OR ST WIDFNING comply with such provisions or this permit shall be deemed OF revoked DINGS STATE ENCROACHMENT PERMIT NO LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter ER 9 (commencing with Section 7000) of Division 3 of the Busl ESS CHARGER nese and Professions Code and my'license is m lull force and _effect TEL NO CANNFC(gN CHARGE Fff License Number, c.- Lic Class C"fLPEWBURSEMENT FEE TRACTOR jjTj j.�y �.ConirOctOr Date�Z�4 RDISTRICT NO CRWv BK MAv PROCFRYD By I am exempt under Sec of the L A Co 3 ��ESS O Plumbing Code and/or Sec of the E INALNEE NO �r' aAss Z DATE \ VALIDATION Z B 8 P Code for the following reason ME RJFT1ON Of WORK FEE p HOUSE SEWER CONNFCTwG TO fINIDDI@r� ^ SEPTICBLIC SEWER er W— / A SEPTIC TAN[ SEEPAGE PitW OR$Ignature WT54ND ORDRAINRFfOHOUSE SEWER CONNECTING TO _ WNER ILD R DECLARATION PRIVAT a Sr TEM1ilI hereby affirm that I om exempt from the Contractors License CONNECT ADDNIGNAE FLOG ORLaw for the following reason (Secton 7031 5 Buisness and Pro WORK TO HOUSE SEWER ACG raOVERFLOW SEEPAGE PIT DaAIMiEE0 .rf@SSIOn3 Code) -� FKTN CESSPOOL DRYWEN MANHOLE ❑ I as owner of the property or my employees with wages as ane REPAIR OR ABANDON HOGSE cGi�7 SEWER OR DISPOSAL SYSTEM then sole compensation well do the work and the structure E' 1 ITEi1` - is not Intended or offered for sale (Section 7044 Business and Professions Code) •v - - ( TOTAL fait 5,�, ❑ l as owner of the property am exclusively contracting with OWNER'S Permit f CHECK 6b. licensed contractors to construct the project (Section 7044 Business and Professions Code) AUTHORIZATION TOTAL FEE 3 �,ypyT� I11 j CONSTRUCTION LENDING AGENCY I HAVE At THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DMILING TO THE PUEt<SEWER for the performance of the work for which this permit Is [[f -0001 77�17C," issued (Sec 3097 CIv C ) SIGNED THIS �IDAY O/FI9 I I (YWNFROI �-� Q . Lender s Name OWNfRR AGF "-' 4518 1 n71 9•-I' AppPE55 lander 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 Stare jaws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter - upon the above me boned property for inspection purposes 5igna of Perm,nee Dote SEE REVERSE FOR EILPLANATORY LANGUAGE WORKERS COMPENSATION DECLARATION hereby offum that I have a certificate of consent to self 200051 DPW Brea nsule or a cLmflcote of Workers Compensation Insurance or 76ABE2D a card led co thereof (Sec 3900 Lab C ) APPLICATION FOR PERMIT Pobcy Nceompony SYYYJE � . ❑ Candled copy Is hereby furnished SEWER - SEWAGE DISPOSAL [LCenified copy is filed wlth'lhe county,burlding Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment DoteiF 4 Applicant E �bT�tE �tn. FOR APPLICANT TO FILL IN CONNECTION DATA CER IFICATE OF EXEMPTION FROM WORKERS ButLOING COMPENSATION INSURANCE A ADORE99 $� v STATION *'� / DEPTH (This section need not be completed if the work involved by the �i MANI♦CLE REFERENCE 8 f•pp UPPER permit is for one hundred dollars (5100)or less ) _ LOCALITY I certify that In the performance of the work for which this NNEEAREST �� TYPE OF CONN KTION UNOTH FROM } permit Is Issued I shall not employ any person In any manner GROSS;SY P E M L TO P L ' so as to become subject to the Workers Compensation Lows DESCRIPTION LOT No Co IM➢ NO PC P 1 No NO Date ' Applicant BLOCK TRACT r TRUNK PERMIT NO{ Y ROAD PERMIT NO NOTICE TO APPLICANT If after making this Certificate of ASSESSOR • .. 4Fn0Avn WAIVER EASEMENT RECORD INSTR NO DATE 9 MAP ASSESSOR PAGE PARCEL Exemption you, should become subject to the Workers NO OF BLDGS Compensation provisions of the Labor code you must forthwith WE OF LOT NOW ON LOT Hwv COST WIDENING comply with such provisions or this permit shall be deemed ME OF revoked BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION FERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER ' 9 (commencing with Section 7000) of Divislom3 of the Busi MAIL s CHARGES and Professions Code and m/license Is in full force and _ effect FRE TEL NO CONNECTION CHARGE EE License Number `�P LIC Class C_�1� ` REIMBURSEMENT FEE yry �^I ' / CONTRACTOR A. v , COnbOCb! Date 0151RICS NO GROUP MAP FQ')E$$f0 BY LTC BS PG ❑ am exempt under Sec of the L A Co rL t�."� TEL NO / �/X27/Z Ltl -j }Plumbing Code andior Sec ofthe � �, GLASS C— Z DATE VALIDATION Z LIC FINAL ZY) OB & P,Code for the following reason DEBCR&TION OF WORK FEE O SEWER CONNECTING TO FINAL Date PUBLIC SEWER By PLIC TAM SEEPAGE PIT ORT IL Signature A PITS AND OR PPAINFIELD a HOUSE SEWER CONNECTING TO N OWNER BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM , 1tl Z I hereby offum that I am exempt from the Contractor s License CONNECT ADO TIONAL SLOG OR Low for the following reason (Secton 7031 S Buisness and Pro WORK TO HOUSE SEWER -♦ f l _ y fesslons Code) s OVERFLOW SEEPAGE PIT GRAINFIELD Ex1N CESSPJOI DRYWELL MANHOLE _ ❑ I as owner of the property or my employees with wages as yWp RE DISPOSAL B5r9rEml HOUSE `lr 17 their sole compensation will do the work and the structure 1 In_ Is not Intended or offered for sale (Section 7044 Business r and Professions Code) ' y 4 ♦ TC FPL 66' .. 51-5 ❑ I as owner of the property am exclusively contracting with 'S licensed contractors to construct the project (Section 7044 OWNERPermit $ 1757 (ITV F� Business and Professions Code) AUTHORIZATION I TOTAL FEE " 3 CONSTRUCTION LENDING AGENCY I HAVE Al THIS DATE A corvmecr WITH THE HEREINNAMED CCIN AaoR I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DA'ELUNG TO THF PUBLIC SEWER for the performance of the work for which IhIs permit is o' Issued (Sec 3097 Gy C ) SIGNED THIS oar of jV[� 30—ofill 7/21,�i2 (YWNER OR Lender s Nome OWNERS ADEN .517 1 aN lender s Address •, RI ADORESS _ 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 !� l< Z/. J42— Slg azure of Per tte to SEE REVERSE FOR EXPLANATORY LANGUAGE