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Home My Public Portal About9158,9152 BROADWAY_Sewer__ WORKERS'COMPENSATION DECLARATION 'pRa000a DPW a/e/ q I hereby- affirm that I have a certificate of consent 'to sell insure, or a certificate of Workers'Comensation.4nsuronce, or 76AU20 pp I�2I�p. a certified cop thereof (Sec. 3800, Lob C.) CE NET ��(�"��®II CI ®� Ir LS II'ltltltl0� Policy No. 10 �48960fompany CAN 1NSUR NIM CO. ®s is ❑ 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 5-10-90 Applicant Ma Bros Plumbing 7nr_. FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' i COMPENSATION INSURANCE ADDRESS 915 BroadLaa STATION �. j DEPTH (This section need not be completed if the work involved by the LocnuiY. Teu�le City MANHOLE REFERENCE: -r UPPER 99 permit is for one hundred dollars ($100)or less.) `s C TION I certify ?hot in the performanceNEAREST TYPE OFLENGTH FROM of the work for which this CROSS ST. Y. P.L. .L.TO P.L. permit is issued, I shall not employ any person i . Cn any manner L. so as to become subject to the Workers'Compensation Laws. P.C.NO. OWNER RJfD DeVelO ❑t CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO, Date Applicant ADDRESS NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY Monrovia EL.No. (818) 359 32T1 Exemption, you should become subject to the Workers' Compensation provisions of the Labor code, you must forthwithLEGAL LEGALDESCRIPTION LOT NO. HWY.OR Si.WIDENING comply with such provisions or this permit shall be deemed ' revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.or BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT I hereby affirm that I Se licensed under provisions f t Chapter USE OF 9 (commencing with Section 7 my of Division 3 of the Bund BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRALTO BT PIUTI Inc. CONNECTION CHARGE FEE License NumberC36-20-167 _231-741 Lic.Class 6-20-16 ADDRESS . 4265 N. Baldwin Ave. REIMBURSEMENT FEE O CITY El Monte CA (SIS) 443-W78 DI2ICT NO. GROUP MAP., PROCESSED BY Contracior(k�n Brod P7tlmhTr vote `I_10-90 TEL.No. \/ eK PG Q Z ❑ I am exempt under Sec. of the L.A.Co. STATE EisE No.231-741 aA C36-20-16 J ce— N0. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the DATETNAU HOUSE SEWER CONNECTING TO ^ DAT VALIDATION m B. 8 P. Code for the following reason PUBLIC SEWER pr SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL 2 Date HOUSE SEWER CONNECTING TO BY ,,tt PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR D OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD ""'--'--- I hereby affirm that I am exempt from the Contractors License EXTN.,CESSPOOL,DRYWELL,MANHOLE 1l Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 10 fes51an5 Cade): SEWER OR DISPOSAL SYSTEM - ❑ I,as owner of the property,or my employees with wages as ACCT.i their sole compensation, will do the work and the Structure '407 �'`,(f,-_II I is not intended or offered for sole (Section 7044, Business t EMS 1 ITEMS and Professions Code). OWNER'S Permit S _. .- . C ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE tc licensed contractors to Construct the project Section 7044, TOTAL 34 - 50 P I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO RACTOR i0 Business and Professions IO Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. C � C CHECK ;4.:.0 y CONSTRUCTION LENDING AGENCY agency /� D __ -CHANGE Lip I hereby affirm that there is a construction lendinga enc SIGNED THIS DAY F (a/ for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT ' ADDRESS 0000-0001 SJiuJSu Lender's Name Lender's Address 13769 1 AM 8:C591 certify that I have read this application and state that the above information is correct. I agree 10 comply with all County ordinances and State laws regulating Plumbing and Sewers, ' jpd�ereb y uthorize representatives of this County to enter a -m estied perry for inspection purposes. 5-10-90 Signalure of Permits Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION I hereby,offirm that I have-a 'certificgte.of consent'to self ^insure; or 6 certificate of Workers'Compensatioq Insurance, or reneasD a certif' p er f (Sec. 3800 Lob C. { ^^ 92W02DPW sten _ p® p /� p pp ® p(� T Policy o Company :5.- H ._ . _ 6"ilr P�L�L��'boP'i�0®p�II�CLI/•+�®� -Ir'��pUtlll� ll . - ❑ Certified copy is hereby furnished. - SEWER V EFS - SEWAGE DISPOSAL f Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY Gdepart eM. date Applicant (J (A'j FOR APPLICANT TO FILL IN CONNECTION DATA- R4 ATA- CE ATE OF EXEMPTION FROM WORKERS' „ Buuow - COMPENSATION INSURANCE ADOREss �,d l/ff STATION Df MH (This section need not be completed if the work involved by the , - MANHOLE REFERENCE vPER LOCALITY 7 L permit is for one hundred dollars ($100)or less.). NEAREST ,rte ttPE OF CONNECnON permit is issued, 1 shall not employ any person in any manner ,LENGTH FROM I certify that in the performance of the work for which this CROSSST. 'Ci �( �� v. ctJRe P.L., M.L.TO PA FROM so as to become subject to the Workers' Compensation Laws. - - - . P.C.NO. .. OWNER CO.IMP.NO. _ JOB NO. • M41L TRUNK PERMIT NO, ROAD PERMIT NO. Date Applicant ADDRESS / NOTICE TO APPLICANLCITY•If, after making this'Certificate of rj j/ 1 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO.. DATE Exemption, you should become subject - -TEL. O.Compensation provisions of.the Labor coda, you LEGAL cthe Workers'u must forthwith DESCRIPTION LOT NO. • HWY.OR ST.WID comply with'such provisions or this permit shall be.deemed y//� revoked., - - - - - BLOCK TRACT. /�.( STATE EN ACHMEM NO.OF B DGS." T. O. - LICENSED CONTRACTORS DECLARATION PERMI SIZE OF LOT NOW ON LOT Ihereby offirm that l am licensed under provisions of Chapter USE OF - Q.(commencing with Section7000) of Division 3 of the BUST- ' BUILDINGS - CHARGES •nen and Professions Code, and my license is in full force and - KM �,. 1 effect CONTRACTOR & /V Sv^ C NECTION CHARGE FEE UUU License Number . �110 ADDRESS . . REIMBUR Contractor Date S CITY DISTRICT NO. GROUP MAP PROCESSED BY z - 8K PG STATE LIC. 2 r ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. - CLA55 / / —Plumbing C6cle and/or Sec. - of the NO. DESCRIPTION OF WORK FINAL HOUSE SEWER CONNECTING To DATE VALIDATION ifn B. 8 P. Code for the following reason PUBLIC SEWER z SEPTIC TANK,SEEPAGE Pit OR FINAL PITS AND/OR DRAINfIELD Date .. HOUSE SEWER CONNECTING TO F . 0Y - PRIVATE DISPOSAL SYSTEM7 Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD �/ U - I hereby affirm that I am exempt from The Contractor's License EXTN,,CESSPOOL,DRYWELL,MANHOLE 10 Low for the following reason (Secton 7031(5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE V - fessionsCode): '- SEWER ORDIs LSYSTEM _ NA ACCT ❑ I,as owner of the property,or my employees with wages as 'T their sole compensation, will do the work and the structure 3307 154,111I .is,not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ _ 1 ITEMS ❑ I,as owner of the property, am exclusively contracting with .AUTHORIZATION TOTAL FEE TOTAL 11i• d� 'licensed Contractors to construct the project (Section 7044, - 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). ' CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. - CHECK t - 154.1313 CONSTRUCTION LENDING AGENCY CHANGE ' n I hereby affirm that there is a construction lending agency SIGNEDTHIS DAY OF 79_r OWNER OR >.' CHANGE .00 - . e for the performance of the work for which this permit is OWNERS AGENT - -' issued (Sec. 3097, Civ. C.). Lenders Nome ADDRESS 01700-0001 '!�lv/y1J Lender's Address • 0763 •1 I certify that I have read this application and state that the - ' abovein r ation is correct. I agree to comply with all County ordina es te laws regulating Plumbing and Sewers,-. - - and re outh Ize representatives of this County to en ' LIDO th above ant ned property for inspection IDLY s Signat of Permittee - Dote SEE REVERSE FOR EXPLANATORY LANGUAGE