Loading...
HomeMy Public PortalAbout5436 WELLAND AVE_Sewer__ WORKERS'COMPENSATION DECLARATION ne e•!.affirm that I have a certificate of consent to self nsure., r a certificate of Workers'Compensation Insurance, or 76A6d2D a cerci 4 d copy thereof (Sec. 3800, Lab C. CE 808(REV 8;81> APPLICATION FOR PERMIT Poticy ).-Company �s ❑ "erti'ied 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' PDESC.RIPTION ING - STATION DEPTH COMPENSATION INSURANCE Ess ' (This section need not be completed if the work involved b the UPPER y LITY MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or fess.) EST TYPE OF CONNECTION I certify that in the performance of the work for which this S ST. LENGTH FROM permit is issued, I shall not employ any person in any manner ''"���'i. ": Y. CURB P.i. M.L.TO P.L. so as to become subject to the Workgrs'Compensation Laws. <,-,w ` P.C.No. ER ��../ wd.''f CO.IMP.NO. JOB NO. 9 �((,,;;;. -014— j °�j r j r TRUNK PERMIT NO. ROAD PERMIT NO. Date 4 Applicant /L-i.l 01 .�-.• 4 Ess54 36 A Q ✓ f F AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Cer4ficate of TEL.NO. Exemption, you should become subject to the Workers' LE Compensation provisions of the Labor code, you must forthwith IPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. TRACT G%'c/� STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION 1 /�NOOFBLDGS. PERMIT NO. F LOT (� NOW ONLOTI hereby affirm that I am licensed under provisions of Chapter f9 (commencing with Section 7000) of Division 3 of the Busi- INGS CHARGES ness,and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE License Number Lic.Class_. ADDRESS REIMBURSEMENT FEE O Contractor Date DISTRICT NO. GROUP MAP PROCESSED BY CITY IV NO. it, STATE. LIC. /// (n BK PG C... � Z ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS S No. DESCRIPTION OF WORK - FEE _ u Plumbing Code and/or Sec. of the FINAL ,� HOUSE SEWER CONNECTING TO DATE /�^ �"��' VALIDAT ON UJ PUBLIC SEWER -�"� (�' �'` ,`' B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR Z PITS AND/OR DRAINFIELD FINA ' Date HOUSE SEWER CONNECTING TO B v 7? 4 PRIVATE DISPOSAL SYSTEM �� Signature CONNECT ADDITIONAL BLDG.OR \ 'f OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER Vii°a yy ry OVERFLOW SEEPAGE PIT,DRAINFIELD �-t qi I hereby affirm that I am exempt from the Contractors License EXTN.,CESSPOOL,.DRYWELL,MANHOLE . ✓u. t Ie v 0. Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE r� 5 fessions Code): SEWER OR DISPOSAL SYSTEM _ ❑ I, 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 and Professions Code). OWNERS Permit $ ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE w-_L I -- licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER, CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ Pilo the performance of the work for which., this permit is OWNER OR OWNERS AGENT issued (Sec. 3097, Civ z). ADDRESS Lender's Name z'r�' .• �. Lender's Address 4ye/5 V 664661? //7 l4j 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 Bove-mentiorted property for Inspection purposes. ` Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE 1 �-pR SRM w Gf- ®rsp0s GN-tx0 N w�Rs� App II+ S �j ADDRS$ Y O� Co CDd S o LQ ARES s ;r ry 13S Cg �y � ;xeex NEpSs sT �'tME ASD Sr"- 'np9 . g GR w $�yDC BSE•COQ apt of S+xtidi� ( OWNER Or- 101 EsY 10TH 'D G 5 � F p1L TEL•N0' YR CON ADDRE54 : MAY pG r � .•� ` L LOT 1 O v a, S. Gs, D15TRlO1 N0 j �A•jA , LEGA % ��ZyylyF+CS1� ��Ek DEsCR1PTlOti TRAOT N Qy�ON LOT DEYTtI W n: N BLDCIC , Sl2E of y0T { A�I0 , ENcf. REF R SE .0ATLE TP ROA4INS N NGOpiSUIL T . TOP CURBG IRATl p CONLy TEL C gpE DO-SS' PED % .t Y B Cl11 dN NO. MLT NO - R 3 OO ROAD PE REGlSTRAT� SCR1Q CONNEGT1t1G 5 INY gip. Np N3gtEO`'EWERSEEPA�jE�D1 OR pIELD SE 00 TRUNK pERN1�RaNC ENT piT�NO OS6EPAG �WE DRtfrD— sl OO TATE ENC. To N0. GE4 pWFRF GESSPO�Di�INECTiNG 00 PERK ] CRAR EiXjOUSE Ep,SAL SYS B Dr, OR $�' INDs e APPROVAL i W P CHARGE PEE URE FST ADDSE$EWER DAN HOUSE St p° 0R S S,GNAT Y�0 KTO1l0 OR ABANTEIA CTION OlNSpE� ALTER•pRPDISPOSRRlRBURSERENfPEE DA1yy i ' a,' P£ tT CON ER ® �O°CAC R a Nkx St NG aev DWELLING NEW nuc SADD'NOR�L sl V411CON G OR plT L `� �� coNtR E DESCR 19�� BUILDIN NK,ses DATE ARE AgpY TICTA P1 SEIPDjpR DRAIN ELL 0 g1� VCI Av oR TORc©S�tjE/ AY OF A DR WE OR T6 TRE PNBLIC AppLl MPL C LTER�L IOSAE 5 E1A 0 GNV_D TNtiS CA A ISR.RSpSp L sY OWNER OR GEN� HAKE REANp�ACSE% R GI7LATING SD SCOO1 NEPjkO NOUSE SE-,Rys fl OWNERS DGE TNAS CORRECS ATE ED AND�pF ARANpO L�SEPTIC 6ESSp0OLS pRE54 NOW LE ABaVE S AND GISTER 4T AYE -V TIL (s B T p°N�0 ) wsr R ADl RgR4A'al JNkpl IVIS t ORp1NANCEAdI PRO��SLGOUNFTgY CF TRF ARpVE SEEP Rp E pll1G� ITN g1NG AND RTl1AB�1L05��E�� YLUN RVI t l / LICstStD4A4OR tl ?ROT CAitf0Rt RESIDEN DESCRIBED Sl o YER TTE 1 1 �f APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEINER--SEWAGE DISPOSAL -•ZPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDINGS ADO'RESS - JOHN A. LAMBIE, County Engineer CASSATT D. GRIFFIN, Supt of Building LOCALITY NEAREST' i FOR APPLICANT TO FILL IN CROSS ST. DESCRIt?7ION LOT N0, .. �:... = - ,.s' OWI4ER BLOCK TRACT MAIL gP� ADDRESS da° 110.OF 11LDGS. SIZE OF LOT NOW'ON LOT CITY TEL, NO. USE OF DISTRICT NO. GROUP a MAP PROCESSED BY EK PG BuIL4ING5 CONTRACTOR ADDRESS CONNECTION DATA — CFTY s' r T1N0. r 7 ''" SPIFid DEPTH STATE IAN10LE REFERENCE REGISTRATION NO. COUNTY LOWER NO. [ DESCRIPTION OF WORK FEE ftOUS,E S WcR C'ONNECTMG°rO - PUBLIC SEWER @ $3.00 _ TYPE DF CONNECTION LENGTH FROM SEPTIC TANK,SEEPAGE PIT OR Y, CURB P,L. M.L.TO P.L. „y FITS`.AND/OR DRAIN.FIELD C«?$3.00 OVERFLOW SEEPAGE PIT,.DRAINFIELD I TXTN..CESSPOOL.DRYWELL $2.00 HOUSE SEWt,R CONNECTING T'0 CO.FMP.NG. J08 N4.+ PRtVAT- DISPOSAL SYSTEM @ 3.00 .�k CONNECT ADDITIONAL BLDG.OR _._. 1R'ORK TO HOUSE SEWER. @ $j,p0 TRUNK PERMIT NO. ROAD PERMIT N0.`il/f {- ALTER.REPAIR OR ABANDON HOUSE STATE ENCROACHMENT SEWER OR DISPOSAL SYSTEM@ $7.00. PERMIT NO. INDUSTRIAL WASTE APPROVAL_ CHARGES OWNEWS PERMIT 3 2 00 CONNECTION CHARGE FES AUTHORIZATION I TOTAL FEJT /V„ zREIMBURSEMENT FEE I HAVE AT THIS DATE:: A CONTRACT WITH TM, HEREIN NAMED CON- _ TRACTOR TO CONNECT THE ABOVE DESCRIBED F.J(.ISTING DWELLING _. APPROVALS DATE �INSPECTOR'S SIGNAIU'RE TO TIME PUBLIC SEWER. ----- SIGNED THIS— DAY OF 19-- NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL ' OWNERS AGENT---__ BUILDING OR WORK SEPTIC TANK,SEE?.PIT($) ADLRESS AND/02 DRAINSIELD I HEREBY ACKNOWEEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT 'THE ABOVE IS COR.R'=CT ANAGREE TO COMPLY CESSPOOL ❑ DRYWE.LL ElWITH ALL COUNTY ORNNANCES AND STATE LAWS REGULATING ALTER REPAIR,SEWER OR I. PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED A.N.D/OR. DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONABANDON CT PL SEWER CALIFORNIA OR THAT I AM THE LEG4 OWNER OF THE ABOVE — DESCRIBED RESIDENT PROP,ERTw y! BACKFILL SEPTIC TANKS ❑ SEEP.PIT(S) ❑ CESSPOOLS ❑ �` SIGNATURE Y° OF PERMITTEE F AI.IDATIQIV ROBERT A. "V's/OOD Com, U.0CASH SUPERVISING MECHANICAL ENGINEER I