HomeMy Public PortalAbout4849 ARDEN DR_Sewer__ WORKERS' COMPENSATION DECLARATION
•1 hereby affirm that I have a certificate of consent to self 6A64TDPWs/69
7
insure, or a certificate of Workers' Compensation Insurance, or 6A6a2D
o certified copy thereof (Sec. Lab C.) APPLICATION FOR PERMIT
Policy No. ��Company Company �at"P F171"C� ,
❑,Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
ertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date 4/7 Applicant Intemi BuihkTs FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS 4849 N. Arden Dr. STATION DEPTH
(This section need not be completed if the work involved by the �+ �T MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100) or less.) LOCALITY Temple City, CA LOWER
I certifythat in the performance Of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
P CROSS ST. Lover Y CURB P L ML TOP L
permit is issued, I shall not employ any person in any manner LEGAL
PC NO
50 a5 t0 become subject 10 the Workers' Compensation Laws. DESCRIPTION LOT NO. CO IMP NO JOB NO
Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT: If, after making this Certificate Of ASSESSOK 260 PAGE 54 PARCEL 21524 AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
Exemption, you should become subject to the WorkersNO.OF BLDGS.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS Single FAmily Home STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER Golden Tree Partnership
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL 7�7
• Almansor CHARGES
Hess and Professions Code, and my license is in full force and ADDRESS 32 N
effect. CITY AlhambraTEL.NO. — 2- 1 CONNECTION CHARGE FEE
D
License Number 627290 Lic.Class B REIMBURSEMENT FEE
CONTRACTOR
rS 4/7/94 DISTRICT NO GROUP MAP PROCESSED BY
Contractor Integral B Me
ADDRESS BK PG
❑ I am exempt under Sec. of the L.A.Co. CITY Walnut TEL.No. 909-869-1075 �./'D/ '�3 }
a
Plumbing Code and/or Sec. of the STATE LIC. FINAL OU
LICENSE NO. 627290 CLASS B DATE ^ VALIDATION
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE 0
HOUSE SEWER CONNECTING TO FINAL
Date PUBLIC SEWER ' O BY Q
SEPTIC TANK SEEPAGE PIT OR W
PITS AND OR DRAINFIELD d
Signature �
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM Z
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER 1
OVERFLOW SEEPAGE PIT,DRAINFIELD
fessions Code): EXTN.CESSPOOL DRYWRL.MANHOLE
I,as owner of the property, or my employees with wages as ALTER.REPAIR OR ABANDON HOUSESEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure _'I.t
is not intended or offered for sale (Section 7044, Business
and Processions Code).
❑ 1, as owner of the property, am exclusively contracting with s .t 10
OWNERS
licensed contractors to construct the project (Section 7044, Permit $ 1:']HL a
Business and Professions Code). AUTHORIZATION TOTAL FEE / /p ?: :;, •7 i.
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO "HANG
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER ® t.; 1-f ,i II,t
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). SIGNED THIS 7th DAY OF April 19 94
Far East Bank OWNER OR
Lender's Name OW NE RS AGENT
Lenders Address200S. Garfield, Alhambra, CA ADDRESS s Above -1i 1 sty
1 certify that I have read this application and state that the
above information is correct.. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
4/7/94
Sigtturel Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE