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Home My Public Portal About9627 WOODRUFF AVE_Sewer__ WORKERS'COMPENSATION DECLARATION �j ..20-0051 DPW 6r8y ! �her�by affirm that ! have a certificate of consent < 71EM420 Insure, or v certificate of Workers' Compensation lnsurcr ,� `":r - a certified copy thereof (Sec_ 3800, Lok,C. APPLICATION FOR PERMIT Policy No. ._._.._.__Company. : Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL I] Certified is filed with the county building irlspe,-!:(,n COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date _ ----__—Applicant _.-_.______ _._ _ FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUI "IN a y� COMPENSATION INSURANCE A.aDHE,.s [J" (t1 'G-�' !r'X y° St ',QP DEPTH (This section need not be completed if the work involved by I: P- aANHCLEREFERENCE UPPER permit is for one hundred dollars ($100) or less.) LOCALTY ( LOWER NF App ST s J ".7 d R TYPE Of CONNECTION LENGTH FROM certify that in the performance of she work for which this CROSS S". r fr'vf ,1 "`f % C ' L l v CURB P L ML Tci P L permit is issued, 1 shall not employ any person in any manner LFCAL P' ra0 so as to become subject to the Workers- Cornpensat,on Lows. DESCRisTION LOT No [p IMP NO (_)B NO BLOCK IRAG' TRUNK PERP I'NO ROAD PERMIT NO Date—_AppLcon?^ _ _ NOTICE TO APPLICANT Ii, after makin hiS Certificate Of ASSESSOR �j� ` • APFi�AV'i NAIYER EASEMENT RE(_^?RD IN5TR NO DATE g MAF't300K PAGtE e PARCEL F/ Exemption, you should become suh!ect to the Workers' NO OFBLDCS. Compensation provisions of the Labor cede you roust forthwith SIZF OF LOT cC L POV)OIN LOT H'AY OR ST WIDENING comply with such provisions or this permit shall be deem i UsE Off revoked BUI_DINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PEaMrt NO — ! hereby affirm that I pm licensed under provisions of Chapter o^ANEW ` 1i 9 (commencing with Section 7000) of Division 3 of the Bus!- MAIL � B � CHARGES ness and Professions erode, and my hrenso is. in full force and ADDRESS - effect CITY FSC TEL No �' f t f'- -coraNECTION c't.tAacE EEE License Number Lic. Class 7, - RE MBURSEMFNT'FF RACTOR CONT Contractor Date DISTRICT NO ';>RGUP MAP . xPROCES,SED By AFI'.,RESS _ 8 PG I am exempt under Sec. of the t A:Cc � - CITY TEL NO. O TO Plumbing Cede and/or Sec.--- of rhe NATE I(; — FNAL +,, LICENSE NO CLASS Oz B. & P. Code for the following reasonNO DESCRIPTION OF WORK FEE r J q/'' t O Hl 7r;,f WLR (iNNfrC,. — �...�A• ...p•ti, Ifd ,�, e Date-.___. PvB c SE�^1ER SEPTiC TANK IEF PA E P'.y OR A P ANL' C,R DRAINPED 300 HO aE JNG TOOWNER-BUILDER DECLARATION PR✓ATE DISPOSAL S,YS`FM Z I hereby offirm that I am exempt frorn the CantroClor'S License LONNECT AnD,T cNAL BLD(, OR Law for the following reason (Secton 7031.5, Buisness and Pro WORK TO HOUSE SewER _ fessions Code): C)YFRFLOW SEEPAGE P T DRAINFfELD )' ErTN CESSPOOL DRYWELE MANHOLF _ C_J 1,as owner of theproperty,or m em Io employees with wages as ALTER REPAIR OR.ABANDON HOUSE y P Y g t SEWER OP DISP,:)5AL SYSTEM the,,sole compervsation, will da the work and the structure - - — iS.not intended or offered for sale (Section 7044, Business /and Professions Code) -i !, as owner of the property, am exclusively contracting with OWNER'S hermit $ licensed contractors to construct the project (Section 7044 _ _ Business and Professions Code). AUTHORIZATION TOTAL FEE CONSTRUCTION LENDING AGENCY HAVE AT THIS DAIE A CONTRACT w TH 111E HFREIN NAME mJTRA( p hereby affirm ihot there Is a constructtOr iendfriq o J3" CNN-C'!HE ABOVE DE.,..Q•BED FX„T;nv ).4ELi,N,. TO THE P.,E f.SEWER for the performance of the work for which this p rrmt Poo issued (Sec. 3097. Civ. C.). SIGNET TFaiS_ LAY OF QVJrvER”,)R Lender's Name _._ •J"E RSA,ENI ADDRESS.—, Lender's Address_ I certify that 1 have read this application and state that ilu above information is ccrrec.t I agree t„. amply with all Count c ordlnonces and State lows regulat no Plumbing and Sewers, and hereF�q�authotl7e representatives of the Co;;nry to e.,tr_r upar rrF cj} ViV_JY,en�on d property for inspectiot?'purpose if, S n tuPh 7p rrne Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION 20-0051 DPVV M-? I hereby offirm that I have a Cerlificote of consent to se '4213 jnSU;,�L�, Of a Certtfiro!e. of Workers'Comn cin pensatiolnsurcf2, 7eA6 "N FOR PERMIT a ii�eq,!ihed`!o?� ihefe,6f (Ser Lob C APPLICATIQ Policy No SEWAGE DISPOSAL I F Ceriiiied copy is hereby furnished. SEWER Certified copy is filed vvtth the coun;y building inspec!;, C COUNTY OF LOS ANGELES BUILDING AND SAFETY department Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTiON FROM WORKERS' Elui CM, DIF RT H COMPENSATiON INSURANCE AML (This section need not be corripLeted if tFe work inoked by!I-.(- REFERFNCF. UPPER permit is for one hundred cloilors ($ICY01) or les.� i LOCALITY i m ( f" 22 — LOWER I Certify that in The performonce �)f the Work for Which ti)is NEAREST 1 .1, ��) T�PE OF LENGTH FROM I"�T V,L TO P 1, CHOS, CURB permit is issued. I shall not empioy any person in ony mannerP NO LOsAL CALITY so as !a become sibiect to the W.-orkers' Compensation Lo,,,,. DEC RIPTiON LCT NO CC IVIF NO JOB NQ Bi_,%K TRACT TRJNK PEi2hAJ NO ROAD PFRWT Ni Date—_—Applicont AFFIC_A:, WAtVER EASEMENT R-coRb )NSTR NO GATE ,NOTICE TO APPLICANT. if, after snaking this Certificate M-AP BOOK 'AGE PARCEL Exernot,on, you should become sublect to the Wo kers' Compenso!.o- provisions of the Labor code, you forthwilh hitt LOT il,Vv OR�" WIDENINC revoked comply with such provisions or this permit sholmust l be deerned U51 OF U il-DING` STATE ENCROACHMENT LICENSED'CONTRACTORS DECI'ARATION PERMIT NO OWNER I hereby affirm that I am licensed under prov;sions of Chapter ZPVil::� 9 (corn'ri Tn 7000) of D,,is,on 3 of the Bu MAIL- encing with Sectic ADDRESS 't, 1,HARCE ness and Professions Code, and m)'I license is in full force and t '-ONNECliON CHAP,'3F FEE effect, CITY I Ei-.NO License Number Lit. Class— REtMfIuRSEMENT FEE Contractor CONTPACTOR DtSTRIC; NO GROP IVAP PROCESSED SY ADDRESS EK PG I art)exempt under Sec. of the L.A Co te arry TEL_NO, le!�_ 0 Plumbing Code and%or Sec-.. f tne. STATE RNA':, LJC,FeNsVIC? CLA•S DATE Ic _VALIDATION z B. & P Code for the following reason— NO, DESCRIPTION OF WORK FEE HOUSE '�:DNNECIINC,IC FiNA, Date C�SE\AN�IEP SHI �FPT!C TAk PAGE P:T Or BY UJI ��TS AND OR SPAINIEL MVi HCL,SE SEWER CONNFCI!,,<-ic OWNER-BUILDER DECLARATION PP;VATE SYSTEM i I hereby offirrn that I am exempt fro the Catilroctor's License CC'NNE-T ADD TONAL ITEMS Low for the following reason iSecton 703'.5, Buisness and Pro WoRk TO HOUH SEIYIW �O TOTAL V54 Of 3 O,IER " - fessIons Code): T DRA!NF[,E1,t' N F�P WELL,M,�N. 400, ALTER OR Air Drxt,� �i 11�x CHECK as owner of the Property, or my employees wttf,wage!;cis y 1541.D) 4 T REP 4 their sole compensot;an, will do he work and the str,)--tueo SEWER O. 11 SPOS SYST is not intended or -,ffereol fi,;r Scilt- Secticin 7044, Business CHANGE and Professions Codes. 'Fj 1, as owner of the pi,operly, 0,1 exclusively Confrcietinq with lffV95 / licensed contrcictor$ to construct the oraieCt (SeOiCin 704A, ow S 12 Business and Professions Code). AUTHORIZATI�N I TOTAL FEE '1'799 PrI12:33 - CONSTRUCT!ON LENDING AGENCY HAVt AT ti,s 'AT� A �,_,NTRACT ,1,!TAF HEREIN NAVE 3 n )Ni%� r that there is a Coristroctian lending ingen, EX ,Tiv( DNEUING TQ TF PUB -SEIA<tp hereby affirm for the perfOrrnance oi the work for which This fie Frl),; issued (Sec. 3097, Civ. C.), Lenclor's Norne Y7,N'R5 Ar;7.lil ADr,,Qt5S_____. Lender's I certify that I have. read this app! cot and state that fk, above inforn-ionon is rorrecl. I ociree to ccmply With all Ce";w, ordiranc d Store j 'P Inws egulol.na Iurnbing and Sewe:s MY .the 111�Aj- ri-�j�r�, and h�Nrllrl�11_.11 ibc�y,e 1ner,Infives of this County to u p 06 spec ton pijij),-se.,, 'A "47 'b`rtjnoir4i��0, perrnqtte Dote SEE REVERSE FOR EXPLANATORY LANGUAGE