HomeMy Public PortalAbout5729TEMPLE CITY BLVD_Sewer (2) 76A642D APPLICATION FOR PERMIT'
AORKERS'COMPENSATIONDCCLARATION CE. 808 (2 SEWER-SEWAGE DISPOSAL
I hereby affirm that I have a certificate of consent to self BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation"tv. n e,or COUNTY OF LOS ANGELES
a certified copy, ergo 3soa, bi �K 1,�,-> CONNECTION DATA
Policy No, ompany 4 I
/ FOR APPLICANT TO FILL IN i
DDEPTH
Certified copy Is hereby furnished. BUILDING UPPER
ADDRESS_ f__ _ � �\
` —f -- ' _ HOLE REFERENCE E -J
Certified copy'is filed with the,Countrui`ding in � jio — _ TV PE of B r
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LOCALITY' �'.- ...� CONNEC ION
MA LENGTH FROM
,.� E — _. n Epi' , M.L. TO P.L..
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. App 7�.r NEAREST _ _�.
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Dat hC ante_--- — CRO55 5T. jr ``f`"t — ,
P.C. Ntl.
l;L,,R'MIC.ATE OF EXI"'IM-fTION FROM WORKERS' �— -� s c ti C�0. IMP. NO. JOB roa.
COMPENSATION INSURANCE OWNER 1
G`
MAIL
Kj3
YUNK PERMIT NO. ROAD PERMIT NO. 0
B
.i` AF-FIOAYIT WAIVER EASEMENT RECOR O.INSTR.NO.
DATE (�
Cfhis section need not he completed if the work involved AODREss �
by the permit is for one hundred dollars 0100) or less.) - - � EL. No. p x
CITY , .�
LALHWY. OR ST- WIDENING
/�(`^ V
I certify that In the performance of the work for which this DES CER IPTION UJ
LOT NO. I f l Y"
permit is issued, I shall not employ any person in any manner
STATE ENCROACHMENT
so as to become subject to the Workers' Compensation Law's. BLOCK TRACT PERMIT NO. to
NO. OF BLDGS.
Applicant NOW ON LOT
..
Date_ pp„ SIZE OF LOT CHARGES
�. NOTICF', TO APPLICANT: It after making this Certificate of USE OF
sExemption, you should become subject to the Workers BUILDINGS
Y CONNECTION CHARGE FEE
Compensation provisions of the Labor Code, you must forth' CONTRACTOR e �:
with comply with such provisions or this permit shall be REIMBURSEMENT FEE
deemed revoked. ( Ii�f tu`� 7SSE'
BYADURE55 !)15TRICT NO, GROUP MAPLIC.I:NSF?pCONT1L.ACTORSDLCIARA.TION - rEL. No. p�° r �C, yji //�� �C /RKC ISY 4.F'4 cj,.I F d^' Jt '�"
1 heresy affirm that l atm licensed under provisions of Chapter Llc. .r "'? "V1' L" F\ f
n
9 (commencing with Sectio7000)of Division 3 ofthe Bus'- STATE, r CLASS
and (5z,`/
LICENSE NO. SA3 .
ness and Professions Code, and my license is in foil force r10. VALIDATION
DESCRIPTION OF WORK FEE FINAL A e �A I,
_.effect. � N � HOUSE SEWER CONNECTING TO DATE.
` n C. ` > PUBLIC SEWER __
License Numbep:3:4 Lic.ClaS$_—�----- SEPTIC TANK,SEEPAGE PtT OR �~J
L -
ITS ANO/DR DRAINFIELP FINAL
s i'$3� - Date I f 3 � — By
ontraCtO HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL•v'Y STEM
CONNECT ADDITIONAL BLDG.OR
I`am exempt from the licensing requirements onala engineer WORK TO HOUSE SEWER
licensed architect Or a registered p OV EHFLOW SEEVAGE PIT,UR AlN PlELO
3L'trng In my professional capacity (Section 7051, BUS` EXTN.,Cr DRYW ELL,MANHOLE ffff////yyyy
mess and Professions Code), ALTU.N.O.ERREPAIR OR AHOUSE .K" �
SF_.WE:R,OR DISPOSAL SYSTEM
I,ic.or Reg.No- ---
IIoNQF.OWNER-BUILDER.DECLARATION OWNERS Permit s
AUTHORIZATION TOTAL FEE
1 hereby affirm that I am exetmpt from the Contractor's
License Law for thefollowingreason (Section 7031.5, Busi-
rle.$$and ProfCS$10nS Code): I HAVE. AT T'F,ACTOR TOHIS CONN ECT THE ABOVE D SCRIB EOHEXISTINGADWELLI Nr<+
TO THE PUBLIC SEWER.
I, as owner of the property, will do the work and the /e__
structure is not intended or offered for sale (Section SIGNED THIS _' DAv of
7044,Business and Professions Code). OWNER OR
OWNERS
CONSTRUCTION LENDING AGENCY ADOREss _
I hereby affirm that there is a construction lending agency
for the performance of,the work for which this permit is
issued(Sec. 3097,Civ.C.)-
Lender's Name----
Lender's
ame— —Lender's Address --'
I certify that I have read This application and state that the
above information is correct.I agree to c�olnly witng arndl C Coul
ordinances and State laws regulating lut
and hereby out torjze re�presentatrles of this.,County to enter SFE 12F.ir1SRSI? FOR EXPLANATORY I,raNCUAGN'
upon the abov� enti ed proprO'y�for in, ection purposes. T
i s
�4
gnature of Per ittee Date