HomeMy Public PortalAbout9158 BROADWAY_Sewer__ WORKERS'COMPENSATION DECLARATION ,
I hereby-affirm that I have a certificate of consent to self 92-0XQ DPW 31 B] q
-insure, or a certificate of Workers'Compensation•Insuranee, or 76AE41D JISI
a certified copy thereof (Sec. 380Q A -EN IN - 'Cf BOB - APPLICATION FOR PERMIT .
Policy No.IO—O'FH96O4ompony GT]A SURAN(� CO. ®s�
❑ Certified copy is hereby furnished. SEWER .- SEWAGE DISPOSAL
®Certified copy-is filed with the county building inspection COUNTY OF LOS ANGELES' BUILDING AND SAFETY ,
department.
Date 5-16-90 Appli<onL oxen Bros P1Lmibine, Inc. FOR APPLICANT TO FILL'IN CONNECTION DATA
.CERTIFICATE OF EXEMPTION FROM WORKERS' BUUD N' - STATION DEPTH '
COMPENSATION INSURANCE ADDRESS 9158 Broady a
(This section need not be completed if the work involved by the - - MANHOLE REFERENCE UPPE
permit is for one hundred dollars ($100)or less.), LOCALITY O R
I certify that in the performance Of the work for which thisCEARLTROSS TYPE OF CONNECTION , LENGTH FROM
V_. CURB P.L. . M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
P.0 NO.
50 a5 t0 beCOme subject to the Workers"Compensation Lows. OWNER D2yelopemnt CO-IMP.NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
• Dote Applicant ADORfss 2 S. Myrtle
NOTICE TO APPLICANT: If, after making this Certificate ofAFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
Exemption, you should become subject to the Workers' CITY 1NonrDVia C11 TEL.No 359-3211 _
Compensation provisions of the Labor code, you must forthwith LEGAL
DESCRIPTION LOT NO. HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed - '
revoked: - R - ` - _--- -,.. BLOCK. ,.TRACT _.: -_. STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO,OF BIGGs. PERMrt No.
1 hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT
>9_(commencing_with,Section7000) of_ USE OF _
_ _Division 3_of_the.Bus1__ BUILDINGS---
_ _ �_ - wARGEs
ness and Professions Code, and my license is in full force and,,
effect. I CONTRAC101(j(gen Bros Plurrbin2, Inc. CONNECTION CHARGE FEE
License Number 231-741 Lic.Class C36-20-16 - }
ADDRESS XM 4265N. Baldwin Ave _ REIMBURSEMENT FEE a
Contractor Owen Bros Pluribi[�te• 5-10-90 g - U
- CITY El'AkJnte TEL.No 443-00TH .DIST ICT�NOJG;� MAP PROCESSED BY
P
STATE LIC, BK G z
❑ I am exempt under Sec. of the L.A.Co. ucENsf No.321-74 I - anss C36-20-16 "� E
Plumbing Code and/or Sec. - of the NO, DESCRIPTION OF WORK HE 111 V, XFIN U
✓ HOUSE SEWER CONNECTING TO ' l\ DA VALIDATION
B. 8 P. Code for the following reason PUBLIC SEWER w
LJ �. M
SEPTIC TANK,SEEPAGE PIT OR FINAL l T Z
Dole PITS AND/OR DRAINFIELD
- HOUSE SEWER CONNECTING TO' BY -
PRIVATE DISPOSAL SYSTEM
Sign OtUre CONNECT ADDITIONAL BLD.OR ► I -'
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER "
OVERFLOW SEEPAGE PIT.GRAINFIELD
I hereby affirm that I am exempt from the Contractor's License ExTN.,CESSPOOL.DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, BUlsness and Pro- AtTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM S
❑ I,as owner of the property, or my employees with wages as ..
their sole compensation,will do the work and the structure. `7G] .4,�I I
is not intended or offered for sale (Section 7044, Business 1 ITEMS
and Professions Code). OWNER'S Permit - $
❑ I, as owner of the property,.om exclusively contracting with AUTHORIZATION I TOTAL FEE TOTAL ,3It ��
licensed contractors o construct the project (Section 7044,
BUSIne$B and Professions I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON ACTOR TO
Code). CONNECT THE ABOVE DESCRIBED E'X'ISTING DWELLING TO THE PUBLIC SEWER. CHECK �'t•C1�
CONSTRUCTION LENDING AGENCY
'I hereby,affirm that there is 0 construction lending agency SIGNED THIS V OF 19 , CHANGE off
for the performance of the work for which this permit is OwNER'OR I ,
issued (Sec. 3097, Civ. C.). OWNERS AGENT
Lender's Name ADDRESS
0000-0001 C /�
.I/1v,i0
Lender's Address 1 A vie;`
I certify that I have read this apPlicafion and state that the .. -
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers, "
' and reby thofize repres totives of this County to enter
u a meNioned erty for inspection purposes.
5 14 90
r Signature of Permltte " Date SEE REVERSE FOR EXPLANATORY LANGUAGE