HomeMy WebLinkAboutNo Permit Number (90)RS ATfON DECLARATION I hereby offirm that I have a certificate of consent -to self -- insure, or a certificate of Workers' Compensation Insurance, or y � 642P ocerfif I(L(c. 3 PC)CEBaBIRFV B.en APPLICATION FOR .PERMIT . . Policy t ��2pony c L�''tl'i� �e'ir�a Casua? t & Surety I A SEWER - SEWAGE DISPOSAL ❑ Certified copy is hereby furnished ❑ Certified copy isfiled with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY I t t epor men . Date Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' - COMPENSATION INSURANCE - '(This section need not be completed If the work Involved by rhe permit is for One hundred dollors (§100) or low.) - 1 certify.thot in the performance of the work for which this Permit Is issued; I shalt not employ anyperson in any manner so o$ to become subject to the Workers'. Compensation.Laws. ._Date Applicant' NOTICE TO APPLICANT: if, -after making this .Certificate of ` Exemption, you should --become subject-to'.the Workers' - Compensotion prayislons of the Labor code, you must forthwith 'comply. with 'such provisions or this permit -shall,-be deemed -- -. revoked." ° - LICENSED. CONTRACTORS DECLARATION - 1 hereby affirm that l am licensed under provisions of Chapter -9 (commencing with Section 7000) of Division 3 of the Busi- - nese and Professions Code, and my license'is in full force and effect.... License Number 343456 - tic. Class B Contractor Ponderosa 'Homo, -ie ❑ I cm exempt Under Sec. of the LA Co. Plumbing Code and/or Sec, of the B. &-P,. Code. for the following reason - - - - Dote Signature -...: OWNER -BUILDER DECLARATION I hereby affirm that i am exempt from the Contractor's License Low for the following reason (Secion 7031.5, Butsness and Pro- - fessions Cade): , ❑ 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). - - © I, as owner of the property, am exclusively contracting with FOR APPLICANT TO FILL IN " i NAVE AY THIS DATf A CONTRACT WITH THE HEREINNAMED CONTRACTOR TO - CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. " CONNECTION DATA BUILDING ADDRESS - C//... STATKNd I V" -DEPTri LOCALITY - MANHOLE REFERENCE G �^ • �' UPPER ER NEAREST r� p q A '.Diamond Lenders Address 2082 Business Cntr, Dr. Trvfne '.. TYPE OF CONNECnON 1,12,0 LENGTH FROM �•, t. CROSS ST 'Bar. above information is correct. I ogreeto comply with all County Y ...CURB P.L M.L. to �Bl rvd. OWNERPONDEROSA HOMES - and herebyy' outhori arep sentotives of this County to enter CO. IMP. NO. - . 'JOB NO. MAIL { }� ADDRESS ..2082 Bus I neSsJ Center /art # 100 TRUNK PERMIT NO '. `. ROAD PERMIT NO., (�tr�Dgr. -'Irvine 833-2180 -' AFFIDAVIT WAIVER EASEMENT RECORD. fNSTR. NO. DATE CITY tELN0 LEGAL 72 DESCRIPTION LOT NO. . HWY. OR ST. WIDENING BLOCK - - TRACT 290534V STATE ENCROACHMENT - NO. OF BLDGS. PERMIT NO. - SIZE Of LOT - NOW ON LOT •'. USE OF. BUILDINGS - CHARGES - CONTRACTOR Ponderosa Homes .. Ponderosa CONNECTION CHARGE FEE ADDRESS- ...'.same as above -... REIMBURSEMENT FEE. '.., � '. DISTRICT NO. GROVP MAP _. PROCESSED BY CITY TEL, NO. STATE - aC. LICENSE NO. CLASS ' AK A - /v C 3 PG ,� ��� � / ',, NO. DESCRIPTION OF WORK FEE - FINAL .`GfR�..ri HOUSE SEWER CONNECTING TO DATE - VALIDATION PUBLIC SEWER "vie SEPTIC TANK $EfPAGE PIT OR - PIIS A ,NOKR DRAMFRLD FINAL HOUSE SEWER CONNECTING TO - By - YSTE PRIVATE DISPOSAL SYSTEM CONNECT ADDITIONAL BLDG. pR WORK 70 HOUSE SEWER OVERFLOW SEEPAGE %T DRAINFIELD ION., CESSPOOL CHIN 11: MANHOLE `- ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM - a979,11 A 'OWNER'S Permit s le s'O # AUTHORIZATION TOTAL FEE y 3'Q ( • r 2 7.5 O', licensed contractors to construct the protect (Section 7044, Business and Profession Code). - - - i NAVE AY THIS DATf A CONTRACT WITH THE HEREINNAMED CONTRACTOR TO - 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,x. for the performance of the .work for which this. permit Is OWNER OR issued (Sec. 3097, Cly. C. - - '. PONDEROSA HOMES OWNERS AGENT '. ..... .- - ... - -. ADDRESS Lender's Name - Lenders Address 2082 Business Cntr, Dr. Trvfne 1 certify that i have read this application and state. that the -_ • ''. _ above information is correct. I ogreeto comply with all County - ordinances and State laws regulating Plumbing and Sewers, and herebyy' outhori arep sentotives of this County to enter upon the aF ove- enhone property, for inspection purposes. - Signature,Pf Per Ifee Date EEE REVERSE FOR EXPLANATORY LANGUAGE - APPROVALS DATE INSRECTOR•S SIGNAT "E NEW HOUSE SEWER O"ECr ADDITIONAL - SUIU]WG�ORWORK ,.__. .-....... ___. _ ._. SEPFICTANK, SEEP, PIT(S) AND/DRDRAINFJELD CESSPOOL ❑ DRYWEa ❑ ;At7HR, PAIR, SEWER OR - 5 AGREE .PAIR, SYSTEM -...-- �• +" dSCONNECi T4:UG AND -, ABANDON FfDUSE SEWER. BACKFILL SEPTIC TANKS - SEEP -PIT 5� [I .:. CESSPOOLS ❑ . _ ... _... _ ... .,_. INSPECTOR'S NOTES 6WNER BCTII,DER t]J2CY,ARA"( N - - - - I hereby affirm that I am exempt from the Contractor's License Lew for the foltowing reason (Section 7031.5, - ...... Business and Professions Code): Any .city or county .. which requires -a permit to construct, alter,: improve, - demothb, or repair any structyre, prior to its issuance, requires tbe;"applicant forsacb peYms to file.a signed 'statement Jbat be is licensed pursuant to the '' '' t provisions of the Contractor's 'License Iaw (Cbapter 9 '(commenc»ig with •Section 7000f,.of D viaiou, 3 of the - $usiness and Professions Zbdej or that be is exempt _ _- ., - tberefrom'gnd the basis fa`r t&:alleged evempil". Any -�, . vioJatior oJS¢ction 7031.5, by tinny applicantfor apenriie -_-._-. ._` • ,. • . " _ _ - subjects the applicant to a civil penalty of not mare than