HomeMy Public PortalAbout6037 CLOVERLY AVE_Sewer__ --WORKERS' COMPENSATION DECLARATION
_ 20-0051 DPW 6/89
P hereby,affirm that I have a certificate of consent to self �6A6azD
Insure, or a certificate of Workers' Compensation Insurance, or .
a certified co�Ythereof�t mp n800, Lob Ct Fahy APPLICATION FOR PERMIT
Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed wit I
he c ty uilding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date L-Li'9� Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEM T N FROM WORKERS' rNGING
COMPENSATI INSURANCE ESS Q37 CI�Jar STATION DEPTH
(This section need not be completed if the work involved by the � MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100) or less.) ITY LOWER
EST TYPE Of CONNECTION LENGTH FROM
I certify that in the performance of the work for which this ST. kC
Tsn� v CURB P L MIL 7o P L
permit is issued, I shall not employ any person in any manner GAL PC NO
so as to become subject to the Workers' Compensation laws. IPTION LOT No. CO IMP No oe No
K TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant
SOR o AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
NOTICE TO APPLICANT: If, after making this Certificate of OOK �d� PAGEPARCEL
Exemption, you should become subject ro the Workers' NO.OF BLDGS.Compensation provisions of the labor code, you must forthwith F LOT NOW ONLOTHWY OR ST WIDENING
comply with such provisions or this permit shall be deemed F �Gp1revoked. INGS 5. 1E.it• STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION L PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter R GL^ � JeL• 11Z �.�' os
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL CHARGES
ADDRESS (0 7 Q� CIC\p
ness and Professions Code, and my license is in full force and {f +�
effect. CITY (l�,n TEL.NO. 7,10 10162 CONNECTION CHARGE FEE
12
License N bet ?"0 LIC.Class y�W� REIMBURSEMENT FEE
ergs �„ r ,
ContractAr CONTRACTOR Dote �^�5 ` DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS .3033 -rte z BK PG
❑ I am a mpt under Sec. of the L.A. Co. /Ay (tt�`,/ }
CITY A l.4_ -,4 TEL.NO. �I i W [r V4{� 1 pf ,3 �i�G 0-
Plumbing Code and/or Sec. of rhe STATE LIC, FINAL V
LICENSE NO. $7 S' C7 CLASS p DATE VALIDATION z
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE //— O
HOUSE SEWER CONNECTING TO FINAL H
Date PUBLIC SEWER BY IU
SEPTIC TANK SEEPAGE PIT OR
�
Signature PITS AND OR DRAINFIELD
HOUSE SEWER CONNECTING TO z
OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM Poo ACCT
s
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG � O
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK To HOUSE SEWER 330357.*
L �
feSSiOns Code): OVERFLOW SEEPAGE PIT DR IELD '�A1, , ` ° t!
EXTN,CESSPOOL DRYWELL ANHOLE � _t1
❑ I,as owner of theproperty, or m em 10 employees with wages as ALTER REPAIR OR ABANDON HOUSE 1 J 1 GI1S
Y P Y 9 SEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure TOTAL 57 .20
is not intended or offered for sale (Section 7044, Business
and Professions Code). CHECK 57.20
❑ I, as owner of the property, am exclusively contracting with OWNERS Permit $ Q CHANGE ,###J
licensed contractors to construct the project (Section 7044,
Business and Professions Code). AUTHORIZATION I TOTAL FEE
CONSTRUCTION LENDING AGENCY HAVE AT THIS DATE A CONTRACT wires THE HEREIN NAMED CON ACTOR Tod �,2�r
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER ® 1—
96
for the performance of the work for which this permit is 7110 1 PM !-*45issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_
OWNER OR
Lender's Name OWNERS AGENT
ADDRESS
Lender's Address
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,
an hereby authorize representatives of this County to enter
up the o entioned property for inspection purposes.
L
nature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
�l
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SE 0508 0203060007
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: SEWER / PTIC: Y BUILDING DDR S:
TR: 6561 LT: 310 EXIST OCC GRP: 6037 CLOVERLY AV
BLDGS. NOW ON LOT: TEMP CA 917802026
ASSESSOR INFORMATIONNUMBER: CONNECTION TYPE: NEAREST CROSS STREET: WOODRUFF
5385-006-006 ORIGINATION• THOMAS PAGE: 596 GRID: J2 LOCALITY: TEMPLE CITY
LENGTH ML TO PL: STATION: DEPTH:
TENANT: MANHOLE REFERENCE: UPPER/LOWER: UED 0 PROCESSED EXPIRES ON:
03/06/02 JK 09/02/02
COUNTY IMPROVEMENT NUMBER:
OWNER: TEL. NO: PLAN CHECK NUMBER: FINAL DATE FINAL BY: CODE:
JOHNSTON SAMUEL JOB NUMBER: 2-7T�- .
6037 CLOVERLY AV TRUNK PERMIT NUMBER:
TEMP 917802026 ROAD PERMIT NUMBER: DESCRIPTION 0F WORK-
AFFADAVIT: NO REPLACE SEWER LATERAL, RECONNECT HOUSE SEWER TO NEW LATERAL
WAIVER: NO
APPLICANT: TEL. NO: EASEMENT: NO
WALTER JOHN MAGUIRE(JOHNIS BACKHOE) (626) 338-6872-
5112 BALDWIN PARK RECORD INSTRUMENT NBRt-__ - RECORD DATE: SPECIAL CONDITIONS:
BALDWIN PARK 91706 HIGHWAY/STREET-WIDENING:--_-�
STATE ENCROACHMENT PERMIT NUMBER•
CONTRACTOR: TEL. NO: j// � FEESn_bY-
3112
D APPROVALS DATE INSPECTOR SIGNATURE
MAGUIRE, WALTER JOHN (626) 338-3872-
BALDWIN PARK BLVD LIC. NO FEE DESCRIPT,-ION' QUANTITYM: AMOUNT: NEW HOUSESEWER
BALDWIN PARK, CA 91706 381152 A ��� �� `j
O1 P,ERMIT'ISSUA.- FE,E 27.75 CONNECT ADDITIONAL
03�CONN TO�P,UBLLC-SEWER 1.00 CON 46.95 BUILDING OR WORK
ARCHITEC OR ENGINEER: TEL. NO: 04;TAP & SADDLEl "' -�Y j �`� 154.00
/I / I TOTAL FEES - - - 228.70 SEPTIC TANK, SEEPAGE PIT
LIC. NO: I V i� � �� �� � 11111� �� ', AND/OR DRAIN FIELD
DRYWELL
y
SEWER MAP BOOK: PAGE �' 1' ��� ���� I "����'� �' ALTER, REPAIR, SEWER OR
' )J �` I SEWAGE DISPOSAL SYSTEM
1����U„
- - - - DISCONNECT PLUG AND
ABANDON HOUSE SEWER
ACKfILL SEPTIC TANKS _
SEEP. PIT CESSPOOL
GR YWATER SYSTEM
REPORT ID: DPR266 ROUTE TO BS05O8