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WORKERS' COMPENSATION DECLARATION-
I hereby affirm that I have a certlficote of consent to self
nsufe, or a certificate of Workers' Compensation Insurance, or ' � 7bA5d]U -
nE BOB (REV 8/81;a cerlified f (Sec. 38!`§tobCl[l APPLICATION FOR PERMIT
Policy Nos8w Company
`' ❑i Cendied c ereby furnished. SEWER - SEWAGE. DISPOSAL.
Xt Certified copy is filed with the county building inspection COUNTY OF LOS.ANGELES BUILDING AND SAFETY
department.
oaie Applicant " ` FOR APPLICANT TO FILL IN., , „ _ .,,,„ • CONNECTION DATA
CERTIFICATE OF E.MP,TION FROM WORKERS'
COMPENSAION"I NSvU RANtE
sectio eed nq{bec,ompleted if the work i n vo lved by the
perm f is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, 1 shall not employ any person in any manner
"so as to become subject to the Workers' Compensation Laws.
Date Appl lcani
N .
OTICE `TO APPLICANT: If, after making this Certificate of -
mptlon, you should become.,, subject to the Workers'
' �npensafion provisions of the Labor code, you must forthwith
.riply with such provisions or this permit shall be deemed
voked.
LIC ENSED'CONTRACTORS DECLARATION _
hereby affirm
that I am censea nde pr•ov stony of Chapter'
9 (commencing with Section 7000) of Division 3 of the Busi-
tress dhd Professions Code, and my license is in full force and,
effect.. ., .... C 34
License Number 474887 Lia Class
Contract. rrPtes
❑ I am exempt under Sec. of the L.A. Co.
ING
N0. DESCRIPTION OF WORK FEE`S` _
HOUSE SEWER CONNECTING TO"' `'
STATION
DEPTH
ESS
P_ -s
d
L y wµ'� UPPER
LITY
L (. MOND B /L D
111.1 lYL JJliil
MANHOLE REFERENCE
OWER
EST
SS ST.
. . ... ... •.`•. ..-••.•••.
•'
TYPE OF CONNECTION ,. `.•...... .,,< -. x+.•n,...x+svHww
THPRd
MIL
Y. CURB P.L M L TO P.L.
SEPTIC TANK, SEEPAGE PIT OR ' �"' '" "_
..... ...,v.0 NO
ER
THE 11LYDEN GROUP
CO IMP NO.
JOB NO.
MAIL
RESS-
FINAL !'1' /T
BY
TRUNK PERMIT NO,
ROAD PERMIT NO.
AFFIDAVn WAIVER EASEMENT RECORD. INSTR. NO DATE
COYina TEL NO
- ...
EGAL..
RIPTION
.. ,..
OT NO.
rRN
HWY OR Si. WIDENING
.. .,, ... _. ...... _._.. ..,,..., ...�......, ...,..
K
TRACT 35754 :.,
,{
STATE ENCROACHMENT
- ____- _. .. ... ... .....�..,...__
Si nafU e l
'
..
PERMIT NO
OF LOT
NOW ON LOTJ1Y
OWNER BURDERDECLARATION :
OVERFLOW SEEPAGE PIT. DRAINFIELD - " ""
. .„..._..........w.,. . _ ,.......oT Tj 3DINGS S:.ngl P. Re�"idence
" I " v "
'CHARc`ISTRACTOR
here Li
by affirm that I am exempt from the Contractor s License , - - ,•
ExTN., CESSPOOL, DRVwELL. MANHOLE
FREEMAN' CONS1.CONNECTION
CHARGE FEE
Law for the following reason (Secton 7031.5, Buisness and Pro-.
RESS
Beechwood 1)r•
REIMBURSEMENT FEE
rM1,,8,225
E111i `C�. Loma T1, NO
-.-.._CLASS
DISTRICT NO.
GROUP
MAP
BK PG
�7 ,T p r•y x j�
SCENSE CWF'.,..:..,..
NO.
.. 474887.
o " r0 •'�
n27,5
P g Code and/o, Sec. of the
" ' ""
N0. DESCRIPTION OF WORK FEE`S` _
HOUSE SEWER CONNECTING TO"' `'
1.7 OO
L
FINAL
DATE
VALID TION
d
-- - -
Pi.nCode
PubUC SEWER
N
Blu$
for the following reason
SEPTIC TANK, SEEPAGE PIT OR ' �"' '" "_
-
PRS AND!OR DRAINFIELD
FINAL !'1' /T
BY
. , " Date,
HOUSE 5EWER CONNECTING TO -'"
//'_ •'Y�
., ...
PR..VATE DISPOSAL SYSTEM `..... _ .' ...
Si nafU e l
'
CONNECT AD017 SE E BLDG, OR
.voRK TO HOUSE SEWER
OWNER BURDERDECLARATION :
OVERFLOW SEEPAGE PIT. DRAINFIELD - " ""
" I " v "
here Li
by affirm that I am exempt from the Contractor s License , - - ,•
ExTN., CESSPOOL, DRVwELL. MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro-.
ALTER, REPAIR OR ABANDON HOUSE
SEWER GR DISPOSAL SYSTEM
1 V
- ?9' -"^'Iona Code):
..
I, as owner of the property, or my employees withwages as
-
o " r0 •'�
n27,5
their sole compensation, will do the work and the structure
is not intended.or offered for sale.(Sectio!rn 7044, Business
Permit - -' s
E` p
rand P ofessions Code) -
OWNER'S
❑ I, as owner of the property, am exclusively contracting with -
AUTHORIZATION
TOTAL FEE
50
.- ? Q �.
. licensed contractors to construct the project (Section 7044,
I HAVE AT THIS DATE A CONTRACT WITH THE�HEREIN NAMED CONTRACTOR TO
EXISTING DMIC1F3G"?'b"'YHE'9b13i1 C'5S`JJER
Business and,p/ofess o s Codei'
-- CONSTRUCTION. LENDING AGENCY
hereby the Is a lending agency
CONNECT THE ABOVE DESCRIS,ED
fpf
SIGNED TH IS 2 DA OF_�ub
1.986
. I off rm that a construction
for the performance of the wok for which th s Per is
P P
owNER oR
OWNERS AGNT 1
issued, (Sec. 3097, Civ. C.).
ADDRESS 8 QQC WOOd • s
14.1'Gci
DIIla
" Lender's. Name
'.
Lender's Address
- ..
I cortify that hhaveread this application and state. that the
...",.
....,
,....... ... ..... ...
._.. _. _.:
above information is correct. agree to comply with all County
-I
ordinances and, State. laws_ regulating Plumbing and Sewers,
Ind hereby authorize representatives of this County to enter
for
up n t e abo a r�re honed property
�,),ie
�I] t i k 6 JSignature
SEE REVERSE FOR EXPLANATORY LANGUAGE
of Permltte9a--
INSPECTOR'S NOTES OViNB.R-S�7ILi�it DECLAlA1ICDD .,.
APPROVALS DATE INSPECTOR'S SIGNATURE i hereby affirm[ that h a- eaeffiPt from the ✓JnCractor's
NEW HOUSE SEWER License Law for the following reason (.'lection 7031..5,
— .. Business and Professiom Code.- Any city or co"ey
CONNECP ADDITIONAL whicb rvgaxires a parsnsit to constrict, after, improve,
SEPTBUILDING TANK, WORK -. „ demolish, or repair any sbuctnYe, prior to its issmance,
AA D%DRINFE�LD TISK - also requires tbc• applicant for mcb pei Wi to file a
CESSPOOL ❑ DRYWEMO signed statement, that be k 'licensed pvsuant to the
provisions of the Contractor's Licem'e Law pCbapter 9
ALTER, REPAIR, SEWER
SEWAGE DISPOSAL SYSTEM m"_ fcomcing &.Kh .lection 7000% of'Dit4sioo 3 of the
DISCONNECT PLUG AND BuT,i.n..�eB..s` and PrflfessiCMts't`.nd,) or that be is esampY
ABANDON HOUSE SEWER _....._ t%Jere%Pa5Y8 and the batisfnr file alleged etXeinptior- Any
vialativn a`S'aaiou 7031.5 b any applicantfor rmit
> y ,!' f pe
sub` is the licaet tv a L>rvil
Tec' app penalty of not more than
,• -
five bandred dollars j5500j.:
.`. .. .... .. .. . ": r
1, as the owner of the Property will do the work, and
; L r �: °; a J..< , .. L, �... � .' `' e s':rnCttrre 9s not intended or offered for sale.
th
. '. .. -..' .. ... .. - .. ... IS". 7044, 8ris19ess' and Pero}essiass Code: 2"Z'._ lon-
... .. ...._." .. '.:. , .. tractors e , doe. scot apply to
:cans Tart ��app an oa of
... ... - X' property who builds lir impsanastbareon, and wlro docs
sucb work himself provided that sack improvements
___......_ are no' ntentded or offered for sale..lf bowever, the
or irriproinment Its sold witirin amme ya.- of
.' completion, the owmer-buiider will bam ice burden
of proving that be did not baits ar improve for the
. pttrposeafsalsj .,.
Y can exempt un4et° Sec.
B &P.%. for this reason
_:_
,.
.. , .. _. -
.. ..
..' -- _..._ ....._.... ... ........_.. .mow ......,_
owner
INSPECTOR'S NOTES .:.
.'..._.....:.. ._._. ..�. - ,. .,> .�. •.�.,. . a� :, - ":-�,:v...: :r. :,, :nru-.-: ._t ars..x..,r.�:.smuc.�:,esrt.,swz�wna::rxs�eri.:
' .y_,,,�„ `. ti �. a -. �. , � •,, «""..: r.. pNfAMi'sPkH6ea9�R�'WI+.gN' TBt�gwnednxrtuMmM+M:> :s •
