HomeMy Public PortalAbout9443 BROADWAY_Sewer__ WORKERS'COMPENSATION DECLARATION
20 0051 DPW 6189
hereby affirm that I have a certificate of consent to sell
'insure, or a certificate of Workers' Compensation Insurance, or 76A642D
a cer,i6ed ca y thereof252 (Sec 3800. Lob C.) .. APPLICATION FOR PERMIT
Pali No 380252@ompany Republic Indemnity
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy 'IS filed with he county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY -
department. 67 -
Dote 6/24/95Appticonl FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS 9433 Broadway 51nuoN DEPTH A 4V!
(This section need not be completed if the work involved by the ' Temple City MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100) or less.) LOCALITY LOWER
I certify thin in the performance of the work for-which this NEAREST NEAREST. TYPE OF CONNECTION 'LENGTH FROM
permit is issued. I shall not employ any person in any manner * CURB PL ML TO PL
LEGAL PC NO
s0 as to become subject to the Workers' Compensation-Laws. DESCRIPTION LOT N0, CO IMP NO JOB NO
DOZE Applicom BLOCK TRACT NON,PERMIT NO - ROAD PERMIT NO
ASSESSOR ATFIDAVIT w4NER EASEMENT RECORD INSTR NO DATE
NOTICE TO APPLICANT: If, after making this Certificate of MAP BOOK PAGE I PARCEL
Exemption, you should become subject to the Workers' No.of BLOGs.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUT LDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER T. S . L. CONSTRUCTION
9 (commencing with Section 7000) of Division 3 of the Busi. noaRESS T .0 CHARGES
mess and Professions Code. and m)•license is'1 in full force
^Jand
� O O
effect. 35'788 C/16 C/J6 CITY San Gabriel TEL,NO. 818/285-7925 CONNECTION CHARGE FEE
License Number 4 Llc.Class
CONTRACTORFrank Marrone and Sons
REIMBURSEMENT FEE •
Contractor Marrone Date 12/31/95 DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS 9860 Lower Azusa Rd . y e, RG
❑ Tom exempt under Sec. of the L.A. Co. CITY EZ 11ci l C 917111 �O —3 a
N0.
Plumbing Code and/or Sec. of the STATE A uc. TwAI O
LICENSE NO. 397884 CLASSC 16 C 3 DATE VALIDATION U
B. 8 P. Code far the following reason NO. DESCRIPTION OF WORK FEE -:Z 14 Q
HOUSE SEWER CONNECTING TO FINAL
Date PUBLIC SEWER (l BY U
SEPTIC TANK SEEPAGE PIT 01 W
Signature PITS AND OR GRAINFIELD i G.
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOW
RRIVATF DISPOSAL SYSTEM D 1t Z
hereby affirm that I
re exempt from the Contractor's License CONNECT HOUSE
BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK OVERFLOW HOUSE SEWER '
fessions Code): EXTN. SEEPAGE RU.ELL MN H {`;(�1` 7 j,11)
E%iN,CESSPOOL DRY WFIL MANHOLE `
❑ 1,as owner of the property, or my employees with wages as AITER,REPAIR OR ABANDON HOUSE
their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM 1 ITEC-,
is not intended or offered for sale (Section 7044, Business ;IITAL 71 - 10
and Professions Code).
❑ I,as owner of the property, am exclusively contracting with 10
I
licensed contractors to construct the project (Section 7044, OWNERS Permit $ IF HINGE .UI.
Business old Professions Code). AUTHORIZATION I TOTAL FEE • A0
CONSTRUCTION LENDING AGENCY i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO '
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED[11SUNG DWELLING TO THE PUBLIC SEWER
for the performance of the work for which this permit Is _II IQII—'I�IIIj Z!1/��?y4
issued (Sec. 3097, Civ. C,). SIGNED THIS DAY OF I9_ //�II �-t n
OWNER OR - 7+:'1'1 1 AN i.
Lenders Name OWNERS AGENT
Lender's Address ADDRESS9860 Lower AZU5a Ed .,, El - Mon e,� Ca.
I certify that I have read this application and state 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
LIpon theove-mentioned property for Inspection purposes. ^
/M /a • 1Y-
Signature of PermiRee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE