HomeMy Public PortalAbout5319TEMPLE CITY BLVD_Sewer (2) WORKERS' COMPENSATION DECLARATION
I hereby offirr* that I yiova a cert f •te of consent to self W=DPW z/8
Insure, or a certificate y Yof Workers en5aho wrance, or 0°A°.ao
aoartif S! o < , `E B°° APPLICATION FOR PERMIT
Pohry Compact As
❑ Certified copy ,s hereby furms ad SEWER - SEWAGE DISPOSAL
xv Ce9ifliso copy Is filed wit he coon building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Dar u Applicant - FOR APPLI NT TO FILL I CONNECTION DATA
RTIFICATE OF EXEMPTION FROM WORKERS BUKDIr.IG
COMPENSATION INSURANCE STATION4?4-17-S DEPTH
(This section need not be completed If the work Involved by the LOCAL" MANHOLE REFERENCE 3 f J O UPPER
permit Is for one hundred dollars ($100)or less )
I certify that in the performance of the work for which thisCRoss ST TYPE OF WNNON ECT' IENOTN FROM
permit Is Issued I shall notiemploy any person in any manner Y Cu" PL ML TOPL
so as to become subject to the Workers'Compensation Laws OWNER CO IMP P!O P C NO
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Data Applicant ADONfBS TRUNK PERMrt No ROAD PERMrt FSO
NOTICE TO APPLICANT If shat making this Certificate of CITY Ut J$4
jV 07A IMVIi WAIVER EASENiEPn RECORD INSTR NO DATE
Exemption, you should become subject to the Workers
Compensation provisions of the Labor code, you must forthwith pESCNPrION LOT NO IrA'Y QRST WIDENING r
comply with such provisions or this permit shall be deemed
revoked BLOCK TRACT STATE ENCROAOwENT
LICENSED CONTRACTORS DECLARATION 40 OF NDGS PERMIT NO
SIZEOFLOT Now ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Bus, [A�
DINGS CHARGES
ness and Professions Code and my license Is I full ce and
effect /� TRACT COWACTION CHARGE PEE
License Nu 00 Llc Class RE"LIRSE)YEW WEE O
Tu wCISTRIC NO MOUP MAP BY VATErsk' ex =❑ I am exempt under Sec of the L A Co 4SE NO � L�Ass ,yt, O
Plumbing Code and/or Sec ofthe DESCRIPTION OF WORK FEE
HHGU&��RCONI. TING TO D � ✓ VALIDATION a
B 8 P Code for the following reason y
SEPTIC TAW! SEEPAGE PIT OR nNAL Z
wAND/OR D/OR MAINFIELD
Date - H SEWER CONNKTING TO BY
PRNA SYSTEM
Signature CONNECT ADDITIONAL BLDG OR ► `
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER
OY1�SEEPAGE LD
I hereby affirm that I am exempt from the Contractor s License EX CESSPOOLDRYWELLLIiLWibl OLE
Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE 10
fessions Code) SEwEWOR NSPOSAL snT '
❑ I,as owner of the property or my employees with wages as _ - - - - - — At CT.i
their sole compensation will do the work and the structure 3�D7 34.50
Is not Intended or offered for sale (Section 7044 Business -
and Professions Coda) OWNER'S Permit S _ — _ i ITEM
❑ I as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A mNruACT WITH TPE „ NAMED coraw,crOR TD - TOTAL 34'�Q
Business and Professions Code) CONNECT TF(ABOVE WTj"ISTwG TO THE PUBLIC SEWER CK
r .SO
CONSTRUCTION LENDING AGENCY
I hereby affirm Phot there Is a construction lending-agency - SIGNHITHIS YOF _CHANI _ 00
for the performance of the work for which this permit ,s o Roe ,.....�
Issued (Sec 3097 Civ C ) owFERS -
Lender a Name
0000-0001 5/17/90
Lender's Address 0745 1 AM10:53
I certify that I have read this application and state that the t
above Information ,s correct I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers
and hereby outhonze representatives of this County to enter
uj6on f e a ove-mentaned progeny far 1 pection purposes {
Signature of Permittee R lbte SEE REVERSE FOR EXPLANATORY LANGUAGE