HomeMy Public PortalAbout4939 DOREEN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION )
I hereby affirm that I, have a certificate of consent to self
ingure, dr o certificate of Workers'Compensation Insurance, or 76A812D 2
•a.certified•gi�Yp fb�,c. 380D, 1�f.)Ins. . Co. 92-IM2 DPW 610 APPLICATION FOR PERMIT
El
Compqny
yfurn SEWER - SEWAGEDISPOSAL,
r❑ Certified copy is hereby furnished.
IJ Certified copy is filed with the county building inspection _ COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date 2-3-92 Applicant Owen Bros. Plumb. FOR APPLICANT TO FILL IN - CONNECTION DATA-
.CERTIFICATE
ATA.CERTIFICATE OF EXEMPTION FROM WORKERS' Dow
COMPENSATIONjINSURANCE - Aooaess " r�f'.�J STATION - DEPTH
(This section need not be completed if the work involved by the LOCALITY1 MANHOLE REFERENCE - UPPER
permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this NEARESTT _ TYPE OF CONNECTION LENGTH FROM
permit is issued, I shall not employ any person in any manner CROSSY. CURB P.I. N,L.TO P.L.
so as to become subject to the Workers'Compensation LOWS. P.C.NO.
OWNER CO.IMP.NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO, DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY Arcadia TEL.NO. . 574-7355
Exemption, you should,-become subject o the Workers LEGAL
. Compensation provisions of the Labor code, you llmust be deemed,
DESCRIPTION LOTNO. HWY,OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT -
ND.OF BLDGS. PERMIT NO.
LICENSED CONTRACTORS DECLARATION - SIZE OF LOT NOW ON LOT
I hereby.affirm that I am licensed under provisions of ChapterUSE OF -
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Profeuions Code, and my license is in full force and
effect EONTRACTOR CONNECTION CHARGE FEE
License Number ' Lia ClassADDRESS Owen Bros.. Plumbing REIMBURSEMENT FEE
Contractor -
231 :741 Date C36-20-16 N. Ba win Avenue DISTRICT NO GROUP MAP PROCESSED BY Z
CITY TEL NO. BK PG / LOQ
Owen BLOS. 2-3-92 STATE L . - L Lsf p W
❑ am exempt under Sec. o rhe L.A.cb. uCENse No. 231- .74L cussC36 0-16 /,?- :5
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK TEE
FINAL d'
1 HOMEE SEWER SEWER CONNECTING TO / DATE VALIDATION U)
B. 8 P. Code for the following reason 2, Z
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR Nn
Date HOUSE SEWER CONNECTING
NG TO BY rll�
- PRIVATE T ADDITIONAL
SYSNAL B -
Signature - CONNECT HOME SEWER DG.OR D
OWNER-BUILDER DECLARATION WORK O SEEPAGE
GEwER
IELD
I hereby affirm that I am exempt from the Contractor's License E�NLLCFSSMOL,DR MAEU.,MANHOLE •'
Low for the following reason (Sefton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
iU
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure ^•"'� •T
is not intended or offered for sale (Section 7044, Business " `_
-,�
.
Permit $ .
and Professions Code). OWNER'S �T --
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATIONTOTAL FEE
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE ACONTRACT WITH THE HEREIN NAMED CONTRACTOR TO '
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. - TOTAL 6.6 ® _'Lv
CONSTRUCTION LENDING AGENCY
15r�Gn �f.,cL
I hereby affirm That there is a construction lending agency SIGNED THIS DAY OF 19_ L-
for the performance of the work for which this permit is OWNEROWNERS AGENT - CHANGE '
issued (Sec. 3097, Civ. C.). ,
ADDRESS
Lender's Name Lender's Address - ill ll ill-)Illl�j 'vjr V927
I certify that I have read this application and state that .the - $js)? 4 'r'I�,',{f
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 -
Sin the DO/ppYe-mentioned p`rp�,1arty for inspection purposes.
� I.GGY
r ignoture of Permits a D6te SEE REVERSE FOR EXPLANATORY LANGUAGE