HomeMy Public PortalAbout5830 SULTANA AVE_Sewer__ W<SktKI,1zS'COMPENSATION DECLARATION 7Gf808 (')t2-$4}
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CE A P LICA f I N F O PERMIT
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I hereby affirn, that I have a certificate of consent to sei£ SEWER`S Po 4 ACS E DISPOSAL
insure, or a. cemficate of Workers'Compensation Insurance,or
a certified Copy thereof(Sec. 3800,Lala.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy;N,( .TR7 i -7�yan. Tni3t� i r1�Z Trt [l
T FOR APPLICANT TO FILL IN CONNECTION DATA
[r,r i'ified Copy is hereby furnished. -- JJ p
F-R
STATION DEPTH 6-<, 6
C ertified coin is filed with the county building inspection �$�� Sult�aAyez_ �� _— Gvv uPPCR
departmentp ) MANHOLE REFERENCE 6+ 1
__2 TION
LaF c NEAREST `� 31 -- �.r LENGTH
1 ER
TYPE OF G CTiON LENGTH FROM
CROSS ST. Y. CURB P.L. M.L. TO P.L.
CER'T'IFICATE OF EXEMPTION FROM WORKERS' 7 :� --- --
P.C. NO.
COMPENSATION INSURANCE OWNER CO. IMP. NO, JOB NO. ^r.
MAIL
(This section need not be completed if the work involved ADD R FSS n� AZTP TRUNK PERMIT NO. ROAD PERMIT N i7T
by the permit is for one hundred dollars ($100) far less.) � � 4F FIDAViT WAIVER EASEMENT RECORD. IN5'rR. NO. fff/// DATE ®"
C iT'Y l � V'TEL. NO. C)
I certify that m the performance of the work for which This LEGAL
permit is issued r .hall not employ any person In any manner DEscRiPTION LOT NO.
so as to become, subject to the Workers'Compensation Laws. HwY, OR ST. WIDENING �o
BLOCK TRACT STATE ENCROACHMENT F? f '
Dateu Applicant.— -- NO. OF i3LDGS. PERMIT NO.
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NOTICE'ICs APPr.ICA�'T: If, after making this Certificate of Si.ZE OF LOT NOW ON LOT--- t CL
USE OF �__� ES
)'.xernption, you should became subject to the Workers' CHARGES
BUILDINGS
Compensation provisions of the Labor Cede, you mint Earth- _ --------- -- _
With comply with such provisions or this permit shall be CONNECTION CHARGE FEE
deemed revoked. CONTRACTor� � 3 - IIT
REIMBURSEMENT PEE
LICENSED CONTRACTORS DECLARATION ADDRESS _-Aye_--
I hereby affirm that I am licensed under provisioirs of Chapter DISTRICT NO. GROUP MAP PROCESSED BY
9 (commencing with Section 7000)of Division 3 of the Busi- E,1 Nth-t 7 .'r EL. No. 5 �rj�4 6 �C C h ��
ness and Professions Code, and my license is in full force and iG
effc Ct. 'CaS:EN 6- " —CLASS
NO. OBJEWIPTION OF WORK FEE FIN6iL ,.'' Fi /VALIDATION(]
HCU SE s WESY CONNE!_'Ta NG TO V
Licensi,Num:ber__R-6-628 Lic.Class 36 _ PO_BL,c SEWER l7 00 DATE
SEPTIC TANK,SEEPAGE PIT OR
b.'rpntraCtQr 7T 77yy��,�. �g /p PITS.AND OR DRAINFIk.LD --_—
FINAL
WWWy� ti r
;J HOUSE. SEWER CONNE® ALSISTING TO FRI`JATE DISPOSAL SYSTEM
I am exempt from the licensing requirements as I am a F
CONK ECT ..SE ONAL BLDG.OR
licensed architect or a registered professional engineer WORK rD HsE SEWER
acting in my professional capacity (Section 7051, Busi- OVERFLOW EEPAGE P1T,ORASNFIEL.D d f
E%TN.,CESSPOOL,DRY'WELL,MANHOLE 6
Inc$$and Professions C,ode), ALTER,REPAIR OR ABANDON HOUSE
SEWER OR D15POSAL SYSTEM ! 3 21,6 A
iris,or Reg.No..------ --Date ---
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HOME,OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNER'S Permit -
License Lave for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE
Sli_'SS.and Professions Code): i HAVE AT THIS DATE A CONTRAC16V!ITH YH-HE RCW NAMED CON-
¢"�1 CON-
I
TO CONNFC.T'T'HE An OV D 4 R1Ei['.D EX15T0 N(_OWL_.LLIh'G 1`?
El I, as owner of the property, will do the work and the TO THE Pu®L1C SEWER. _i 0,1 C;Jde 8 5
structure is not intended or offered for sale (section slcNEo THIS _ od�lYIlCtYt�19S1
7044, Business and Professions Code). OWNER OR
OWNERS AGENT—
CONSTRUCTION LI:NDINt ACL:NC! ADORES.S'-- , _Ay __7 T'
I hereby affirm that there is a construction tending agency
for the Performance of the work for which this permit is
issued (Ser:. 3097,Civ.C.).
Lender's Name
Lender's
I certify that I have read this application and state- that the
above information is correct.I agree to comply with all County
ordinance:; and State laws regulating Plumbing and Sewers.:
and hereby authorize rei3resentatives of this County to enter
upon th,'above-nAnti.ortend property for inspectiourposes.
SEF REVERSE FOR EXPLANATORY LANGUAGE
sure of Perm.itte T3ate.
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