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No Permit Number (92)
RS ATfON DECLARATION I hereby offirm that I have a certificate of consent -to self -- insure, or a certificate of Workers' Compensation Insurance, or bM642D Pat tLc. 3 �., CEBaBIREy PPLICATION FOR .PERMIT . Policy l � Pan ��� �elir�a Casua? ty &Surety ®, D Certified copy i3 hereby furnished SEWER SEWAGE DISPOSAL ❑ Certified copy isfiled with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY I t t spar men . Date Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' - COMPENSATION INSURANCE ' - '(This section need not be completed if the work involved by the permit is for one hundred dollors (5100) or low.) - 1 certify.thot in the performance of the work for which this Permit Is issued; 1, shall not employ anyperson in any manner so os 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, -i. ❑ 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 (Seaton 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 HEREIN NAMED CONTRACTOR TO - CONNECT THE ABOVE DESCRIBED E%I STING DWELLING TO THE PUBLIC SEWER. " CONNECTION DATA BUILDING ADDRESS - $TAT*" C% V" -DEPTri . LOCAUTY - - MANHOLE REFERENCE G �.. 19 UPPER NEAREST r� p q A '.Diamond vd. '.. TYPE OF CONNECTION LENGTH FROM �•, CROSS ST 'Bar. • ''. _ Y .CURB P.L M.L. to P.l.,/ �Bl OWNER PONDEROSA DrERO A{ HOMES - CO. IMP. NO. - 'JOB NO. MAIL }� ADDRESS .270822 BusineSs Center /art # 100 TRUNK PERMIT NO '. `. ROAD PERMIT NO., Ali r�Drr. -'Ervine 833-211LA/ SEE REVERSE FOR EXPLANATORY LANGUAGE - AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE CITY tELNO LEGAL .72 . D ESCRIPTION LOT NO. I 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. '.., I '. DISTRICT NO. "'OUP MAP _. PROCESSED BY CITY TEL,NO. - STATE LIC. LICENSE No. CLASS ' lQ e3 AK PO NO. DESCRIPTION OF WORK FEE - FINAL HOUSE SEWER CONNECTING TO DATE - VALIDATION PUBLIC SEWER .VI ®O SEPTIANDC TANKrO� SEEPAGE PIT OR ' P115 DRAINFRLD � FINAL - HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM- BY 11,4 - CONNECT ADDITIONAL BLDG. OR " WORK 70 HOUSE SEWER OVERFLOW SEEPAGE %T DRAINFIElO ExTN., CESSPOOL ORYfNEI1. MANHOLE `- ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM - a979,11 A OWNER'S Permit s le s'O #:.% e,-10! iQI AUTHORIZATION TOTAL FEE y ;510 (• r 2 7 Q', licensed contractors to construct the project (Seniors 7044, Business and Professions Code). - - - i NAVE AY THIS DATf A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO - CONNECT THE ABOVE DESCRIBED E%I STING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending'agency SIGNED THIS DAY OF 19,x. oil. for the performance of the .work for which this. permit Is OWNER OR issued (Sec. 3097, Cly. C. - - '. PONDEROSA HOMES OWNERS AGENT '. ......_ - ... -ADDREES -. Lender's Name - Lenders Address 2082 Business Cntr, Dr. Trvfne 1 certify that i have read this application and state, that the -_ • ''. _ above inis correct. I ogreeto comply with all County - ordinances and State laws regulating Plumbing and Sewers, and herebyy' outhorj7e rep sentatives of this County to enter upon the aF ave- IB hone property for inspection purposes. - Signatur f Per tree Date SEE REVERSE FOR EXPLANATORY LANGUAGE - APPROVALS DATE INSKCTOR-S S'GNAT "E NEW HOUSE SEWER O"ECr ADDITIONAL - SUIMWG�ORWORK SEPFICTANK, SEEP, PIT(S) AND/DRDRAINFJELD OESSPM [I osyma C] ;AL7HR, 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 B J1LDER 'DJ2 ,ARA'i` ON f 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 - whicb requires -a permit to construct, alter,: improve, - demothb, or repair any structyre, prior to its issuance, requires tbe;"applicant forsacb permit to file. a signed statement Jbat, be is licensed pursuant to the provisions of the Contractor's 'License Law (0apter9 '(commenc»ig witb'Section 7000f,.of Dviaiou,3 of,tbe - -' J -mess and Professions Zbdej or that be is exempt _ _- ., - tberefrom'gnd the basis jai the: alleged evempil". Any -�, . vioJatior oJS¢ction 7031.5, by tinny applicantfor apenriie subjects the applicant to a civil penalty of not mare tban