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WORKERS' COMPENSATION DECLARATION-
I hereby affirm that I have a certificate of consent to self
nsuie, or a certificate of Workers' Compensation jnsurii or � 7bA5d]b
QnE sB
OB (REV8/81;
a cerlifiedf (Sec. 387tab Cu[l APPLICATION FOR PERM
IT
Policyo Company
eby furnished. SEWER - SEWAGE. DISPOSAL
Ceryfied copy Is filed with the county building inspection COUNTY OF LOS.ANGELES BUILDING AND SAFETY
:. department. ... - ,.. ...,.M. ...,...,�..,...
Gate Applicant ' ` FOR APPLICANT TO FILL IN., , „ - .,.,„- CONNECTION DATA
CERTIFICATE, OF, TM
AION FROM WORKERS'
SURA�CECOPENSON'IN.
- (Th s sectio eeci notbe completed if the workinvolved by the
perm f is for one hundred dollars,($100) or less.)
Icertify that in the performance of the work for which this
man—permit is issued, 1 shall not employ any person in any
ab as to become subject to the Workers' Compensation Laws.
Date "App l leant
NOTICE `TO APPLICANT' If after making this Certificate of -
mption you should become.,, subject to the Workers'
' �npensation provisions of the Labor code, you must forthwith
.riply with such provisions or this permit shall be deemed
"revoked.
LICENSED 'CONTRA( -TORS DECLARATION' '
hereby
affirm
that I am censea underpr'ov stony of'Chapter'
9 (commencing with Section 7000) of Division 3 of the Busi-
"wess "cZ Professions Code, and my license is in full force and,
effect.. . 474887 ., .... C 34
License Numb
er Lia Class
Contractor rP_ TttY'PPRI�]TI"Dates"�/s�H
❑ I am exempt under Sec. of the L.A. Co.
ING
NO. DESCRIPTION OF WORK 'HEL
HOUSE SEWER CONNECTING TOl7
STATION
.. ,... ....^.^..._+.,., ,,,-.w
DEPTH
ESS
r -DrLIPPER
d
4 L y
LITY
L (. MOND B /L I
1111 lYL JJliil
MANHOLE REFERENCE
OWER
EST
SS ST.
. -..... .. :.-•..• ,. ^ `•. ..-••.•••.
"
TYPE OF CONNECTION ,. '..•. ..... .,,< -. x+.•n,...x+svHww
THPRO
MIL
Y. CURB P.L M L TO P.L.
SEPTIC TANK, SEEPAGE PIT OR
EEPACAELD
p�
..... ...,vD NO",.„
ER
THE 11LYLJ. N GROUP
CO IMP NO.
JOB NO.
RESS
s
-'" -
TRUNK PERMIT NO,
ROAD PERMIT NO.
'L pp (�
8lV +96iu-9
AFFIDAVIT 'WAIVER EASEMENT RECORD. INSTR. NO DATE
O
COYina TEL NO -
- ...
FGAI..
...RIPTION
.. ,..
LOT NO.
rA
HWY OR Si. WIDENING
.. ... _. ...... _._.. .,,..., . .�.,...., ...,..
K
RACT 35754
STATE ENCROACHMENT
___ _- _. ...... .. ...._....,.__
nafU e l
..
PERMIT NO
OF LOT
NOW ON LOTOF
OWNER BURLIERDECLARATION
rfrom
SEEPAGE PIT.
@H
Single Residence
"v"Law
}.DINGS
CHAR(`iESTRACTOR
LiOVERFLOW
by affirm that I am exempt the Contractors_License „,�
ExTN., CESSPOOL, DRVwELL, roAnHol"I
ELL? ?"
HFEE
FREEMAN' CONS1..T
CONNECrION CHARGE FEE
for the following reason (Secton 7031.5, Buisness andPro-.
RESS
8225 JJ,PyeCi1WOOC1 �i• .
REIMBURSEMENT FEE
rM1, p,E
E111i C�. Loma TE,. Nod %x.`4/980-4429
-.-.._CLASS
DISTRICT NO.
GROUP
MAP
BK PG
PROCESSED BY
STATE�7 ,l p by x j�
CWF'., ...,.. .:�(!
NO.
.. 474887.
" r •0he
-
g Code and/o, 5ec.' —of the
NO. DESCRIPTION OF WORK 'HEL
HOUSE SEWER CONNECTING TOl7
OO
L
GATE
VALID TION
d
-
PUBLIC SEWER
N �[�J
V%
Blumbin
. & P Code for the fol Lowing reason
SEPTIC TANK, SEEPAGE PIT OR
EEPACAELD
p�
- -
PETSAVANK,
FINAL l//'r_"•'YJJ`� '�
"
HOUSE SEW CONNECTING TODate
PRIVATE DISPOSAL SYSTEM ”"here
nafU e l
CONNECT ADDITIONAL BLDGORSi
.voRK ro HousE sewER
OWNER BURLIERDECLARATION
rfrom
SEEPAGE PIT.
@H
"v"Law
LiOVERFLOW
by affirm that I am exempt the Contractors_License „,�
ExTN., CESSPOOL, DRVwELL, roAnHol"I
ELL? ?"
HFEE
for the following reason (Secton 7031.5, Buisness andPro-.
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEMVI,
"'^'ions Code):
as owner ofthe property, or my employees with wages as
" r •0he
sole cam ensation, w o l e war ❑n t❑ structureLq
Ss not intended, or offered for sale Section7044
�Code). ., Business
Permit�their
)Uand
Professio
OWNER'S
I, as owner of the property, am exclusively contracting with
AUTHORIZATION
TOTAL.
5O
2 Jlicensed
contractors to construct the project (Section 7044,
I HAVE AT THIS DATE A CONTRACT W TH THEHEREIN NAMED CONTRACTOR 10
EXISTING bCNEL WG"?'bY17E' saBLIC'SISNER""
Business ❑gd,PjafesS a s COae).'
-- - CONSTRUCTION. LENDING AGENCY
hereby the is a lending agency
CONNECT THE ABOVE DESCRIaD
SIGNED TH IS 2 DA OF_�ug
1.98b
. I off rm that a construction
for the performance of the wok for which this ermit is
P P
OWNER A
1 00 r 1
OWNERS AGNT
issued (Sec. 3097, Civ. C.).
:
ADDREss 8 5 beecriwood 1W.,
)ata
OIIla
..
" Lender's. Name "
Address
_
I certify ihafhhaveread this application and state that the
-
above informotion is correct.agree to comply with all County
_1
ordinances and, State.. laws_ regulating Plumbing and Sewers,
and herebyy authorize representatives of this Courtly to enter
for
up n t is abo a rpe boned property inspection urposea.
�I] t i k 6 JYV�C d SZt� l
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
-' •: " :.., - :: e. INSPECTOR'S NOTES --.."-,QWNER-BU1LDF-R DECLARAT'IOIN' .,.,.
APPROVALS DATE INSPECTOR'S SIGNATURE i hereby affirm that h a- z tewpt Trott: the Contractor's
NEW HOUSE SEWER License Law for the following reason (. oisien 7031..5,
— .. Basiness and Professi+or s Code).- Any city or county
CONNECP ADDITIONAL whicb regsxires a pannsit to constrict, after, improve,
SEPTBUILDING TANK, WORK demolisb, or repair any structure, prior to its issmance,
AA D%DRINF ESTISK LD - ai o requires the applicant for mcb pei wi to file a
cEssPGDL ❑ ptYWEtiO signed statement, that be is licensed pvsuant to the
provisions of the Contractor's Licem'e Law lCbapter 9
ALTER, REPAIR, SEWER OR _ ,COm9neYSCing 8U^.'Xh Section 7000% OfIJSf➢iSin98 3 q,' the
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
Business` and Prnfessionr Cod) Or that be is exempt
ABANDON HOUSE SEWER _.. ".._ t%Jere%Pa5Y8 and $be basis for file alleged exeinpti0r- Any
vialatian a`S'ecsion 7031.5 b any applicantfor rmit
> y ,!' f pe
subjects the licaet tv a L�ivil
Tec' app penalty of not more than
as the property will the properwill do the work, and
five list
the Structure is not intended or offered for sale.
. '. .. -..' .. ... - - ... (Sec. 70 sisss�ss' and Professions Code: 2" '._ an-
_. e , doer,. scot apply to
tractar�a :cans irsrt ��ap an oz
-. - ... ... .... ;. .. prroperty who builds or impsavas' tfiareon, and wlro doe�.s
.... ..... _ sacb work himself provided that suck improvemen$s
are noC Intended or offered for sale..lf bowever, the
or improvement u sold witban ane yaar of
,... -. eornpletioa, the owner-baiider will baw ehe burden
of proving that be did not buidar improve for the
. purpose ofsale)
Y can exempt un4er Sec
r
B &P.%. far this reason
_.
DRte
owner
INSPECTOR'S NOTES .:.
' may_,,,.„ ".ti �. a �. , �' •,, 1."' ..: r.. pNfAMi'sPkH6ea9�R�•WI+.gN' TBt�gwnednxrtuMmM+M:V :s•