HomeMy Public PortalAbout4853 ARDEN DR_Sewer__ WORKERS' COMPENSATION DECLARATION 20-0051 DPw6t89 pp
1 hereby affirm that I have a certificate of consent to self TUU}
insure, or a certificate of Workers' Compensation Insurance, or 76A6420
a certified copy thereof (Sec 3800, Lob C.) APPLICATION FOR PERMIT
Policy'No. 1264366 Company State Fund
❑ Certified copy is hereby furnished.
�ySEWER - SEWAGE DISPOSAL
,r�voCertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND,$,AFETY
department.
Date 4/7/94 Applicant Tri oral Rui ld rs, FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS 4853 N. Arden Dr. STATION DEPTH
(This section need not be completed if the work involved by the Temple City MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY LOWER
I certify that in the performance Of the work for which this NEAREST T TYPE OF CONNECTION LENGTH FROM
P CROSS ST. Lower Azusa Road Y CURB P L M L TO P L
permit is issued, 1 shall not employ any person in any manner LEGAL
PC NO
50 a5 10 become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO. CO IMP NO JOB NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant
ASSESSOR AFFOAVIT WA7 EASEMENT RECORD INSTR NO DATE
NOTICE TO APPLICANT: If, after making this Certificate of MAP BOOK 260 PAGE 54 PARCEL21524 F
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
ness and Professions Code, and my'license is in full force and ADDRESS 3 2 N. AlmanSOr CHARGES
effect. CITY Alhambra, CATEL-NO. CONNECTION CHARGE FEE
License Number 627290 Lic. Class B REIMBURSEMENT FEE
CONTRACTOR Irate al Builders DISTRICT NO GROUP MAP PROCESSED BY
ContractorT_nte=al Rui lcders 4/7/94
ADDRESS f/ BK PG
❑ I am exempt under Sec. of the L.A.Co. CITY Walnut, CA TEL-NO. 909-869-1 O7 � a
Plumbing Code and/or Sec. of the STATE LIC. FINAL
LICENSE NO. 627290 CLASS B DATE q VALIDATION 0
0
B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE —�_ { Q
HOUSE SEWER CONNECTING TO FINAL
Date 1 PUBLIC SEWER Q BY 0
SEPTIC TANK SEEPAGE PIT OR W
IL
Signature PITS AND OR DRAINFIELD
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM
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 a
OVERFLOW SEEPAGE PIT 'c, DRAINFIELD � '"
I ,
feSSiOnS Code): EXTN CESSPOOL.DRYWELL MANHOLE --
74
❑ I, as owner of the property, or my employees with wages as ALTER,REPAIR OR ABANDON HOUSE �`;•s Sn '.'
their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM
is not intended or offered for sale (Section 7044, Business
and Professions Code). T(_(^!+L 7 1 10
❑ I, as owner of the property,am exclusively contracting with __,r ih
licensed contractors to construct the project (Section 7044, OWNER'S Permit $ t: t,::_ �.s
Business and Professions Code). AUTHORIZATION TOTAL FEE Q , s..;yNRSE o h
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ® _
I hereby affirm 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
slued (Sec. 3097, Civ. C.). SIGNED THIS 7th DAY OF April 19 24 �.
OWNER OR _ �, v c;".,
Lender's Name Far F 4 Bank OWNERS AGENT 3 iw _ j:; _,43_,
Lender's Address 200 S Garfield, Alhambra, CA ADDRESS )S*e aS 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 lows regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
Upon the above-mentioned property for inspection purposes.
Si atur o Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE