HomeMy Public PortalAbout5329TEMPLE CITY BLVD_Sewer (2) WORKERS'COMPLNSATION DECLARATION 78A842D
CE 808 (2 eo) 71C, APPLICATION FOR PERMIT
1 hereby affirm that I have a certificate of consent to self SEWER—SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(See 3800 Lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
........ STATION STATION DEPTH
❑ Certified copy rs filed with the county building inspection won-Eff 2 t L �L
department
UPPER
Locwm L MANHOLE EXPERIENCE LOWER
LOCALITY
Date ' Applicant NEww K"T
TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' cROu fT L I V 6 Y CURE P L M L TO P L
COMPENSATION INSURANCEr PC NO
OWn[w c CO IMP NO JOB No
(Thu section need not be completed If the work Involved w..... 2 GE T1�1(- rwunK PERMIT Ho Rowo PERMIT Ho >
by the permit u for one hundred dollars ($100) or less) APP..AV.T .wm�Nr ...... ...TR AOI
DATA Zj_
CITY ( TEL NO — 2
1 certify that in the performance of the work for which this L[oAL
permit B issued, I shall not employ any person in any manner DESCRIPTION LOT No 0
HWY oR ST WIo[H.Ha
so as to become subject to the Workers' Compensation Laws U
BLOCK TRACT STATE 6NCROwCHN[HT
Date Applicant NO OF SLOGS PERMIT NO d
NOTICE TO APPLICANT If after making this Certificate of SIZE OF LOT Nov ON LOT Z
Exemption, you should become subject to the Workers USE OF CHARGES
Compensation provisions of the Labor Code you must forth BUILDINGS
with comply with such provisions or this permit shall beCONNECTION CHARGE PER
deemed revoked conrw escrow
LICENSED CONTRACTORS DECLARATION ADDRESS REIMBURSEMENT PEE
I hereby affirm that 1 am licensed under provisions of Chapter ouTw.cT no awoV P MwP Pwoc ufo.T
9 (commencing with Section 7000)of Dimino 3 of the Bust CITY TEL NO J(/'J • I@9'
ness and Professions Code and my license u in full force and �1c erQ.fQ No � c�wee 5,0(/ r` p
effect HO DESCRIPTION OF WORK PKQ
.W.. C....=T.Ho To FINAL VALIDATION
License Number Lie Class .U�Lic.aw.w DATE
u•nc TAR. •ae Pwaa PTI ow
Contractor Date .,T•wwoJo.o.A..P.e..o —AFINAL
F1 .OV.. •.w.w.o....r..o To .-- -.-.�t-
1 em exempt from the licensing requirements as 1 am a •R.VwrA o.•Po•AL•r•r.M By
licensed architect or a registered professional engineer w0"N N t.W...0 ADDITIONAL.Loo OR
acting 1n my professional capacity (Section 7051 Bus .RPLow•.[PROs .n owes
mess and Professions Code) «T• =...loot DO IN LL
PA."ON w .PON HOV•w L
ALTER o w
Duro.AL araw
Lie or Reg No Date
HOME OWNER BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's OWNER'S Permit t �R 1 5 7 4 A
License Law for the following reason (Section 7031 5, BUS, AUTHORIZATION TOTAL FEE
Ness and Professions Code) va • THIS DATA w CONTRACT v R.IN HAMao c # O
i.ACTOA i. co.n.cT THE A"OVa DE Gnu�oHi wuuwa
1, as owner of the property will do the work and the To T.. PV•uc•[w.n 2 4 O O '
structure is not intended Or offered for sale (Section SIGNED THIS DAV OF K
7044 Business and Professions Code) OWH.R 0"
. o.nT � • " Q O O x
U
CONSTRUCTION LENDING AGENCY ......
1 hereby affirm that there is a construction lending agency - 1 016-81
for the performance of the work for which this permit is
Issued (Sec 3097 Civ C)
Lender's Name
Lender a Address
I certify that I have read this application and state that IhL
above information is correct I agree to comply with all County I
ordinances and State laws regulating Plumbing and Sewers
and hereb authorve representatives of this County to enter
upon th bove mentionedgrope y for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of P
ttee Date f