The URL can be used to link to this page

Home My Public Portal About4819 WILLMONTE AVE_Sewer__ WORKERS'COMPENSATION DECLARATION •76A6420 APPLICATION FOR PERMIT CE 308 (2-t"s01 I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE �� insure, or a certificate of Workers'Compensat• I Insurance,or COUNTY OF LOS ANGELES BUILDING AND SAFETY a certified Co y th f(Sec. 380 alh - .i Compan Policy No.l FOR APPLICANT TO FILL IN CONNECTION DATA ❑ Certified Copy is hereby furnished. BUILDING T S'T'ATION DEPTH ADDRESS UPPER Certified copy is filed with un buildin s tion MANHOLE REFERENCE fIi'r7rtmen LOCALITY LOWER Date12 r Appll(,gn NEAREST TYPE OF ON NECT FON LENGTH FROM CROSS ST. Y. CURB P.L. M.L. 70 P,L. CERTIFICATE OF EXEMPTION FROM WORKER' P.C. NO. COMPENSATION INSURANCE OWNER CO. IMP. NO. JOB No. MAIL ff TRUNK PERMIT NO. ROAD RMIT NO. > (This section need not be completed if the work involved ADDRESS 1 CL by the permit is for one hundred dollars (S1U0) Or less.) yam+ `Ai'FIOAVIT WAIVER EA$EMEN RE RD.INSTR.NO. DATE CITYTEL. NO. �y." V I certify that in the performance of the work for which this LEG L' cr permit is issued, I shall not employ any person In any manner DESCRIPTION OT NO HWY. OR SX WIDENIN O so as to become subject to the Workers' Compensation Laws. BLOCK TRACT STATE E"NCROAC E L) PERMIT NO. U,I Applicant NO. OF SLOGS. Q• Date SIZE OF LOT NOW ON LOT ch NOTICE TO APPLICANT: If, after making this Certificate of USE OF CHARGES Exemption, you should become subject to the Workers' BUILDINGS a; Compensation provisions of the Labor Code, you must forth- _ CONNECTION CHARGE FEE ?! with comply with such provisions or this permit shall be CONTRACTOR •i' deemed revoked. t REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDR 10 J DISTRICT NO. GROUP MAP PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter TEL. NO BK PG CITY 9 (commencing with Section 7000)of Division 3 of the Busl STATE LIC. ness and Professions Code, and my license is in full force and LICENSE NO. CLASS effect. NO. DESCRIPTION OF WORK FEE FINAL VALIDATION HOUSE SEWER CONNECTING TO C]1( �p i • PUBLIC SEWER DATE ' License Number Lic.Class - SEPTIC TANK,SEEPAGE PIT OR --- rl (,A� PITS ANO/OR DRAINFIFLD FINAL r,• ni" ContractoQ Date + f HOUSE SEWER CONNECTING TO BY 1r-YI PRIVATE DISPOSAL SYSTEM Y. U I am exempt from Y e licensing requirements as I am a 4 CONNECT ADDITIONAL BLDG.OR licensed architect or a registered professional engineer J WORK TO HOUSE SEWER ) fi - ' OVERFLOW SE..EPAGE PIT,DRAINFIELD ,IfJ.jy acting In my professional capacity (Section 7OS1, Bus- E%TN.,CESSPOOL,DRYWELL,MANHOLE iness and Professions Code). ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic.or Reg.No. Date FIOME OWNER-BUILDER DECLARATION —T— I hereby affirm that I am exempt from the Contractor's AUTHORIZATION License Law for the following reason (Section 7031.5, Busi- TOTAL FEE nes$and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I, as owner of the property, will do the work and the To THE PUBLIC SEWER. structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19__ 7044, Business and Professions Code). OWNER OWNERS AGENT ENT, ' CONSTRUCTION LENDING AGF-NCY ADDRESS I hereby affirm that there is a Construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. 1 agree to comply with all County ordinances and State laves regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter up le ab ve-menti ted prc erty for spection purposes. SEE REVERSE.FOR EXPLANATORY LANGUAGE },y Signature of Permittee ate w rg 24650 INSERTS CBAG96. 'sA6ua®®O APPLICATION FOR ■ ERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL - DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION ButLDING �� gax .ADDRES5 r1VILLIAM A. J SENCnp S of Buald°>Rg LOCALITY .NEAREST , FOR APPLICANT TO FILL IN _ceoss ST. LEGAL -- - �, :, - - DESCRIPTION LOT NO.4!' n � _OWNER - BLOCK TRACT Jk' MAIL `a _ ADDRESS NO.OF SIZE OF LOT NOW ON LOTS CITY 1 TEL. NO. ��r USE OF .. . BUILDINGS Di STRICT NO. GROUP MAP PROCESSED BY BPC PG f' CON TRACTO (r'" e � :.. ADDRESS ...� CONNECTION DATA r _ CITY s TEL.NO. � ®� STATION DEPTH STATE MANHOLE REFERENCE UPPER. REGISTRAN N0. --y" NO, �TIOESGRIP i N OF WORK FEE COUNTY : - LOWER HOUSE SEWER CONNECTING 70 _ PUBLIC SEWER Ga $3,00 6F lefTYPE OF CONNECT 6N LENGTH FROM SEPTIC TANK, SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L. -- PITS AND/OR DRAlNFIEL.D @ $3.00 _. OVERFLOW SEEPAGE PIT, DRAINFIELD _ EX.TN.. CESSPOOL,DRYWELL C@ $2.00 _ HOUSE SEWER CONNECIING TO P.C.N0. PRIVATE DISPOSAL SYSTEM @ $1.00 Co.IMP.N0. JOB NO. CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO, ROAD PERMIT N0. WORK TO HOUSE SEWER @ $1.00 _ t3 ALARALTF�R.REPAIR 3R ABANDON HOUSE STATE ENCROACHMENT OR DI POS.AL SYSTE 4p $1,00 PERMIT N0. 14 0 INDUSTRIAL WASTE APPROVAL ta7 CHARGES n OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE ,AUTHORIZATION TOTAL FEE ar 6 REIMBURSEMENT FEE 1 HAVE AT*THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS I DATE !NSPECTOR'S SIGNATURE TO THE PUBLIC SEWER. a SIGNED THIS DAY OF 19— NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT-�az— --'C y''" _BUILDING OR WORK - - �- ADDRESS_ _ _ SEPTIC TANK,SEEP.PITS) -- AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE. ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Q DRY'WEL.L L`l WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALDER,REPAIR,SEWcR OR PLUMBING AND SEWERS, DISPOSAL SYSTEM E DIS DIS I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DfSCONe CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER. I DESCRIBED RESIDE. AL PROPERLY. BACKFILL SEPTIC TANKS (] 1 's a SEEP..PIT(S) L CESSPOOLS [ SIGNATUREF PERMTTE ' _.�F...__..�..__.{. VALIDATION ROBERT A. WOOD C& M.o. (�, CASH SUPERVISING MECHANICAL ENGINEER