HomeMy Public PortalAbout4851 ARDEN DR_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 20-0051 DPW 6189
insure, or a certificate of Workers' Compensation Insurance, or 76A642D
o cert fled copyahereof (Sec. 3800, Lab C.) APPLICATION FOR PERMIT
Policy No. 1264366Company Sta Tnd SEWER - SEWAGE DISPOSAL
❑lertified copy is hereby furnished.
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment.
Date 4/7/94 Applicant Integral Builders FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS Temple
N. Arden Dr STATION DEPTH
(This section need not be completed if the work involved by the LOCALITY em le Cit MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) NEAREST
OWER
I certify that in the performance Of the work for which this CROSS ST. Lower Azusa Road TYPE OF CONNECTION LENGTH FROM
Y CURB P L M L TOP L
permit is issued, 1 shall not employ any person in any manner LEGAL PC NO
so as to become subject to 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 makingthis Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOOK 260 PAGE 54 PARCEL 2152
Exemption, you should become subject to the Workers' NO.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 Partnershilp
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL N. Almansor CHARGES
Hess and Professions Code, and m)l license is in full force and ADDRESS 32 Np O
effect. (� I CITY Alhambra CA TEL.No. 818-282-0931 CONNECTION CHARGE FEE
License Number 627290 Lic.Class B REIMBURSEMENT FEE
CONTRACTOR
Contractor IntocIral BL7ilIh'S 4/7/Q4 DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS 829 S. Lemon., All—B BK PG
❑ 1 am exempt under Sec. of the L.A.Co. clry Walnut TEL.No. }
p 909-869-1075 ��� '3 a
Plumbing Code and/or Sec. of the STATE LIC. FINAL U
LICENSE NO. 627290 CLASS B DATE r,_dVALIDATION
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE J ( o
HOUSE SEWER CONNECTING TO FINAL •�,!_.i_j r,g (—
Date PUBLIC SEWER BY V
SEPTIC TANK SEEPAGE PIT OR
Signature PITS AND OR DRAINFI E LID --' Cn
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO ►PRIVATEDISPOSALDISPOSAL SYSTEM -i U11-- 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 i;:s E; a m -10
fessions Code): OVERFLOW SEEPAGE PIT.DRAINFIELD .„,
EXTN.CESSPOOL DRYWELL.MANHOLE F_.H)_CK 1" '..11-g
❑ 1, as owner of the property, or my employees with wages as ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure • rill
is not intended or offered for sale (Section 7044, Business
and Professions Code).
ti-S
I, as owner of the property, am exclusively contracting with �y 7 U i,r��s_�=_f's�_i -
OWNERS Permit $ 11/0
licensed contractors to construct the project (Section 7044, _ t
Business and Professions Code). AUTHORIZATION TOTAL FEE /0 5;02'3
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ,
I hereby off rm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). SIGNED THIS 7th DAY OF Aprll tq 94
,.,
OWNER OR
Lender's Name Far East Bank OWNERS AGENT
Lender's Address 200 S. GArfieldAlhambra, CA ADDRESS S S Above
I 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
Sign Lure cVermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE