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Home My Public Portal About5448TEMPLE CITY BLVD_Sewer (2) WORKERS COMPENSATION DECLARATION hereb- off.rm that I have a certificate of consent tc self 700051 DPW 81118 mswe tr a certificate of Workers Compensation Insurance or 78A]Ei 1 y certified copy thereof (Sec 3800 Lab C �_ � Policy N a� a ny ate, `-`� APPLICATION FOR PERMIT ❑ Cerldted copy Is here�urmshed I SEWER - SEWAGE DISPOSAL W Certified copy is filed with the county budding Inspe n „ COUNTY OF LOS ANGELES BUILDING AND SAFETY departure t / ///yyy,,,�..�� Dale � � Applican��^ / ' FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS / BUILDING COMPENSATION INSURANCE AOORESS L! c STATIC' aPIN (This section need not be completed if the work Involved by the MANHOLE REFERENCE UPRER permit is for one hundred dollars ($100) or less ) LOCALITY L R NEAREBi - LYRE Of CONNECTION rT F LEt.IGIN FROM I certify that in the performance of the work for which this - CROSSST Y CURB PL ML TOPL permit is Issued I shall not employ any person in any monner LEGAL y9 PC NO so as to become subject to the Workers Compensation Laws DESCRIPTION XJ LOT NO a CO IMP NO IpB NO Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT ND NOTICE TO APPLICANT If after makingthis Certificate of ASSESSon !//•l Q�3 AFFIDAVIT WAIVER EASEMENT RECORD iNSTR NC) DATE Exemption MAP BOOK .70 3 PAGE PARCEL p you should become sublect to the Workers Compensotion provisions of the labor code you must(dSIZEOF LOi NO of SLOGS 7J .� ^ NOVION LOT comply with such provisions or this Permit shall be deemedeemed use OR Nwr OR Sr WINNING revoked BULGING,✓ • V STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT tip I hereby affirm that I am licensed under provisions of Chapter OWNER 9 (commencing with Section 7000) of Division 3 of the Bus. uAI1 p ness and Professions Code and mill license Is In full force and ADDRESR egx -C t� CHARGES effect l .I ^� �� CITV �f TEL NO �/ CONNECTION CHARGE FEE License Number S6 L.c Class /V•{ / �/� CONTRACTOR a *G• PEIMBURSEMENI FEE Contractor r le �-V<� �y w DISTRICT NO G P MA' BY AOORE95 T(//�J v • pRGrI om e.empl under Sec of the L A Co �OJ��SMD > CITY / TEL NO Q 11CIL Plumbin Code and/or Sec of the STATE '/` LIC VY g IUCENSENO �jr uAss L-3(e•l� o iL 77--�s VALIDATION z B & P Code for the following reason NO DEBCFBPTION OF WORK FEE .�'i Q HOUSE SEWER CONNECTING TO FINAL Date PUBLIC SEWER BY v IC TANK SEEPAGE PTT Do 4 Signature PITS AND OR DPA W1 to W OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING 10 ► z PRIVATE WSPOBAL SYSTEM I hereby affirm that I am exempt from the Contractor s License CONNECT ADOinONAL BLDG OP Law for the following reason (Secton 7031 5 Bmsness and Pro WORK TO HOUSE SEWER lfl fessions Code) OVERFLOW SEEPAGE PIT DRAINFIELD EKTN CESSFCKOL MYWELL MANHaf ,1l it .A ❑ I as owner of the property or my employees with wages as ALTER REPAIR OR ABANDON HCA/SE T'EL 1 their sole compensobon will do the work and the structure SEWER OR DISPOSAL SrStEA. t 3301 Jb.zJ Is not Intended or offered for sale (Section 7044 Business and Professions Code) 1 ITEM ❑ I as owner of the properry am exclusively contracting witha e licensed contractors to construct the project (Section 7044 OWNER'S Permit S .6 TOTAL tEf] .7•J Business and Professions Code) AUTHORIZATION I TOTAL FEE CHECK 56.225- CONSTRUCTION .rJCONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACIOR TO L(JE//��``''//��C� rr�� I hereby affirm that there .s a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING D.VEuwG TO THE PUBLIC SEWER CHANGE .1IL) for the performance of the work for which this permit Is issued (Sec 3D97 Cry C ) SIGNED THIS DAY OF 19_ ��fT�fTf�I� OWNER CW t [MGMUV 1 l/210�7c Lender s Name OWNERS AGENT lender s Address ADDRESS 9535 1 PM11:1? I certify that I have recd this appLcoNon and stale 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 ve merl Prope inspection purposes Signature of Permittee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE I