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Home My Public Portal About5561 SULTANA AVE_Sewer__ — % i WORKERS'COMPENSATION DECLARATION -N I hereby off irm that I hove a certificate of consent to self W4XXX2 DPW a/N q `insory, or a certificate of Workers Compensation Insurance or 7�M /ISI a certified copy thereof (Sec 3600, Lab ), Ls 909 APPLICATION FOR PERMIT Policy No Company Aa O 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' COMPENSATION INSURANCE �A sTASTATION -1 1,. I (This section need not be completed if the work involved by thetOCAurY ZE'. Cl g nSAleiOtE REFERENCE L FUER permit Is for one hundred dollars ($10D)or leu ) UNGtH FROW I certify that in the performance of the work for which this CROs ST $) �] }( r TYPE OF CONN�ION FD ML roPt permit is issued I shall not employ any penon in any manner so as to become subject to the Workers'Compensation Laws Ory SULTANA COW NO PC toeNO NO 7{fG(LJO MAL TRUNXPERALTNO ROPDPEAhVTNO Dote Applicant A SSvAu;FvRum g CITY-M OF INWSTW No 818 3307886 AFF�AVIr wA1VER EASEMENT REcoRD INSra NO DATENOTICE TO APPLICANT If after makm this Certificate f Exemption, you should become subject to the Workers' Compensation provisions of the Labor code, you must forthwith DESCCRFTXO LOT NO HWY OR ST WIDENING comply with such provisions or this permit shall be deemed revoked BLOCX TRACT STATE ENC3rC AIEM LICENSED CONTRACTORS DECLARATION PTD OF BLDGS tETVWT FID I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT I� NOW ON LOT 9 (commencing with Section 7000) of Division 3 of the ELI 9CHARGESUSEOF GS /+ i tress and Professions Code and my license Is in full force and effect CDNTI CTgL poauCONNECTION CHARGE PEE License NumberSs'7607 Lic Clan SM-ENT 3RIG. Y ADDRESS REIMBURSFMWt HE tl . Contractor BLUEBELL DEV.Date 7/12/88 CT, Ci'1'SC DDla^micr NO GRpIP MAv PROCESSED BY v J ` / I SK Pc ❑ I am exempt under Sec of the L A Co L NSE NO 532602 LIC $ r O NO DESCRIPTION OF WORK fEE Plumbing Code and/or Sec of the nNu /I W X SEWER CONNECTING i0 DATE _ .L VALIDATION N B 8 P Code for the followingreason o SEPTIC TANK SEEPAGE RT OR RTS AND/OR DRAINHDD BY = Date HOUSE SEWER CONNKTING i0 BY PRN. D 5 Signature CONNECT ADDITIONAL BLDG OR OWNER-BUILDER DECLARATION `VO TO HOUSE SEWER ;vol 4, 1 A I hereby affirm that I am exempt from the Connector's License PAGE PIT DRAINFIEU)cense EJRN CESSPOOL DRYWEu LMNROLE # E • •,•,J 0 Low for the following reason (Secton 7031 5 Buisneu and Pro- ALTER REPAIR OR ABANDON HOUSE fenions Cade) SEWER OR DISPOSAL SYSTEM I • - 2750 ❑ 1,as owner of the property or my employees with wages as their sole compensation, will do the work and the structure • E e 2 7.5 0 c=.. Is not Intended or offered for sale (Section 7044, Business 0 7. 2r&88 and Professions Code) OWNER'S Permit S 10 ❑ I as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE 7 licensed contractors to construct the project (Section 7044 I HAVE AT THIS DATE A CONTRACT WTIH THE HEREIN NAKED CCxJLRACTOR i0 Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCY Pilo hereby affirm that there is a construction lending agency SIGNED THIS DAV OF t9_ for the performance of the work for which this permit is OWNER OR Issued (Sec 3097 Civ C ) OWNERS AGENT Lender's Name TOKAI SANK OF CAIJMIOTIA Lender a /la�^1 SIX S'I. I06 ANC�CFS CA. I Zertify 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 thR above-�mepntioned propertyfor inspection purposes 1. V J[A.Y J2, 1988 Signature of PermitteeDate SEE R[VERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION ovw s I herpbr affirm that I have o certificate of consent to self veAeAx insure or a certificate of Workers Compensation Insurance or CE Bae ' o Policy ed copy thereof(Sec ny Lab C , APPLICATION FOR PERMIT Policy No Company ®a ❑ 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' / mmu 5561 Sultana AVfllLle STATION i-// I DEvrH COMPENSATION INSURANCE AA (This section need not be completed If the work Involved by the LOCALITY Zile C1tY, CA '',+ REFERENa '�{.'tSE 3 34r Our u permit Is for one hundred dollars ($100)or lessO. ) LETNGTH PROM I cetyl that in the HA E Y TYPE CURB PL M L TO PL certify performance of the work for which this cRoss sr permit is Issued, 1 shall not employ any person In any manner PC No so as to become subject to the Workers Compensation L ws / OWNER CO IMP No )De NO V Date?/( Applicant Amass 14428 E. Vali Blvd. BUNK PERMIT NO NAD PERM TNO '" . I AFFIDAVIT I WAIVER EASE RECORD INSTR NO DATE NOTICE TO APPLICANT If after making this Certificate oy air - - Exemption, you should become subject to the Workers UGx Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO HWY QRST WIDENING comply with such provisions or this permit shall be deemed revoked ELLOCK TRACT STATE ENCROAOINEM LICENSED CONTRACTORS DECLARATION NO of IRDGS PE ND SIZE OP LOi NOW ON LOT 45-, y 3 17 i!1 I hereby affirm that I Se licensed under provisionsofChapter LnE as �T7ft � 5• l.�f aJ /e W 9 (commencing with Section 7000) of Division 3 of the Busl- eulLDlrvGS auutGEs ness and Professions Code, and my license Is in full force and effect CONTRACTOR CONNECTION CHARGE HE V License Number 5"47607 LIC Class B t/ ADDRESS 14428 E. Vaney Blvd. REIMBURSEMENT FEE 6 OrsrRlCr No GROUP MAP o er O Contractor Dev• Date 07/12/88 v C X (818) 336-30961 M 7,(/ z ❑ 1 am exempt under Sec of the L A Co '/ LICEW NO Inwss „J IL �U ��I L /+ O tq DESCRIPTION OF WORK HE ~ Plumbing Code and/or Sec of the DATE W HOUSE S�EWEER CONNECTING i0 DATE VALIDA ION a B & P Code for the following reason y SEPTIC DIO PAGE LPITD OR HNAL Z PG AND/OR DitAICONNECTING Date PRWATSEWER CON YSTEM, i0 BY PRIVATE DISPOSAL Y Signature m NECT ADDITIONAL NDC OR OWNER BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Controctor s License EOXTNHCE55P�OE DRYWEEU.PAGA PIT NHOILE Low for the following reason (S«ton 7031 5, Bulsness and Pro- .ALTER REPAIR OR ABANDON HOUSE fessions Code) �R OR DaPDSAL SYST�A ;201 3 9 A ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure �•� \ # R! a R\1 0 Is not Intended or offered for sale (Section 7044, Business ' and Professions Code) I OWNER'S Permit $ _ ( • e 27,5 0 ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to COnsnUat the project (Section 7044 I HAVE AT THIS DATE A COMRACT WHIN TIE HEREIN NAMED CONTRACTOR TO R R - 27,505 Business and Professions Code) DONNECI THE ABOVE DESCRIBED EXISTING DWELUNG TO TIE PUBLIC SEWER CONSTRUCTION LENDING AGENCY , 07 1 2,�8 8 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 AGENTADorEss " Lender's Name TOW BA'14K OF CALIM1d1IA Lenders Address 534 W SIX I certify that I have read this application and stare that the above Information Is correct I agree to comply with all County ordinances and Stole lows regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned proper for Inspection purposes V _�aaa/�Z�— Ju1Y 12, 1888 Signature of Permittee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE Wt-ORKET S CdMPENSAT{ON DECLARATION I here DPw 3/'D r 1� by pttom that I have a certificate of consent to wlf 7e 2t) u • coeurs rn a cmLficate of Workers Compensation Insurance or - ` E Policy ied copy thereof(Sec ny Lab C , `E APPLICATION FOR PERMIT Policy No I Company ms ❑ Certified copy ishereby 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 eunDING /a�, t COMPENSATION INSURANCE ADDRESS I T"LV-�=s STATION ✓T DEPTH (This section need not be completed if the work involved by the G`• FAANI/IXF REFERENCE UPPER permit is for one hundred dollars ($1O0)or less ) LOCALITY ]gt�j � s L I certify that in the performance of the work for which this �Sysr t.J�'� TYPE DF CDNEffCTKJN 1ENGTH FaoM Y CURB ➢l M L TOP l permit is issued, I shall not employ any person In any monner 1 C NO so as to become subject to the Worl ers Compensation ow!' pWryER +& ' 1 Y e� CO IMP NO JOB NO MAILDate a Applicant ADDRESS 1� Z TRUNK PERMIT NO ROAD PINSTR NO NOTICE TO APPLICANT If, after making this Certificate o AFFIDAVIT WAIVER EASEMENT RECORD INSTR rq DATE Exemption you should become subject to the Workers' Compensation provisions of the Labor code, you must forthwith DESCUvjKTN LOT NO HIM OR ST WIDENING comply with such provisions or this permit shall be deemed revoked BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION No of aLOGs - PERMIT SIZE OF LOT NOW ON LOT I hereby affirm that I am Ilcenwd under provisions of Chapter NSE of 9 (commencing with Section 7000) of Division 3 of the,Busi- ness and Professions Code and my license is in full force and �1 1 �U t effect ��Z/��_ ' rj CONTRACTOR PCl kC cOK MIDN CHARGE FEE License Nulmmb�ei I fT��—�]s.�,�� LIc Clas's—/ �7 ,4pORE35 REIMBURSEMENT FEE a CcmtractorL2Am�` LmvDate L�I Z( �[J �Y TEL NO �3 DISTRICT NO MAP ➢ROCES�ED BY V (� BK PG = TE ❑ I am exempt under Sec of the L A Co LICENSk NO �6pZ Ct 5 O Plumbing Code and/or SecNO r of the DESCRIPTION OF WORK FEE DATE W _ HOUSE SENOR CONNECTING To DATE VALID ON W B &P Code for the following reason SEPTICPUBLIC TANSEATK m K TANK SEEPAGE PITW OR RNA / Z PITS AND/OR GRAINFIELD Date r1W5F SEWER CONNECTING TO BY i PRNA DI NAL H Signature CONNECT ADDITIONAL BIDG Oft OWNER-BUILDER DECLARATION sown To HousE SEWER hereby Offifm that I am exempt from the Contractor's License ExTNCVIEp CESSPOOL DRyyWEU�NFIE Law for the following reason (Secton 7031 5 Buisness and Pro- ALTER REPAIR OR ABANDON 40115E ;201 & Q A fesslons Code) SEV/EA OR DISPOSA SYSTEM, ❑ I as owner of the property or my employees with wages as - # - ! • - 1 0 their sale compensation, will do the work and the structure < , I \ V �,v-1 27. 50 is not intended or offered for sale (Section 7044, Business pgfmtt S and Professions Code) OWNER'S ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE -- Is - 27.506 licensed contractors to construct the project (Section 7041, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 07.1 2 -88 Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE P IC 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 Cw C ) OWNERS AGENT ' ADDRESS lender s Name Lender a Address _ I certify that I hove 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 herebyauthorize representatives of this County to enter upon the above-mentioned props for inspection purposes Signcture of Permittee V Date SEE REVERSE FOR EXPLANATORY LANGUAGE