HomeMy Public PortalAbout4943 FIESTA AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affirjr�,. fhot I -have a certificate of consent to self 20-OOSi DPW 6189
insure, or'a certificate of.Workers' Compensation Insurance, or 76A642D
a certified co y there a
ff (Sec. 3800, Lab C. APPLICATION FOR PERMIT
Policy No ElCertified 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 2'-;IL Applicant %%o/fi0 1!51714-11, FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS STATION /T 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.) LOCALITY
NEAREST TYPE OF CONNECIJON LENGTH FROM �f
I certify that in the performance of the work for which this CROSSST. /1—��d vCURB P L ML TO P L d
permit is issued, 1 shall not employ any person in any manner LEGAL PC NO
so as to become subject to the Workers' Compensation Laws, DESCRIPTION LOT NO. CO IMP NO JOB NO
BLOCK ��.�� TRACT !( TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate Of ASSESSOR �j 2 AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
g MAP BOOK ���0 PAGE�� PARCEL f�/
Exemption, you should become subject to the WomterS' NO.OF BLDGS.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT x, NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION /_ PERMIT No
I hereby affirm that I am licensed under provisions of Chapter OWNER (��
9 (commencing with Section 7000) of Division 3 of the Busi- ARIL � ���� CHARGES
y
ness and Professions Code, and mlicense is in full force and ADDRESS
effect. CITY .e ~ TEL.NO. J V� CONNECTION CHARGE FEE
License Number V[� `� Lic. Class � REIMBURSEMENT FEE
Contractor W /� Dote J Ste^ CONTRACTOR V �
// _ fJ�J_^ /J DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS r!O •'�" (T�(/'.CI�� BK PG
❑ I am exempt under Sec. of the L.A. Co. /J y 5"l , / O
CITY �CK 6 TEL.NO, v V _�
Plumbing Code and/or Sec. of the STATE LIc. FINAL U
LICENSE NO. CLASS DATE1 o AVALIDATION Z
B. 8 P. Code for the following reason NO. DESCR c TION OF WORK FEE `�~ O (X Q
HOUSE SEWER CONNECTING TO FINAL
Date PUBLIC SEWER BV C7
SEPTIC TANK SEEPAGE PIT OR LU
Signature h PO AND OR DRAINFIELD
a
NER-BUILDE' DECLARATION HOUSE SEWER c ro Z
PRIVATE DISPOSALL SYSTENG SYSTEM
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR a
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER y_
OVERFLOW SEEPAGE PIT. DRAINFIELD '
feSSiOnS Code): EXTN,CESSPOOL DRYWELL,MANHOLE
�.�-'i'
ALTER, REPAIR OR ABANDON HOUSE "»- -
,❑ 1, as owner of the property, or my employees with wages as SEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure 5 x =i �,_,_
is not intended or offered for sale (Section 7044, Business
T MQ
and Professions Code). s .L _.._
❑ I, as owner of the property, am exclusively contracting withOWNERS Permit $ ��p _ Y+_ ❑ _ ❑
licensed contractors to construct the project (Section 7044,
Business and Professions Code). AUTHORIZATION1 TOTAL FEE
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 EXISTING DWELLING TO THE PUBLIC SEWER ® 11,11-Ji-
for
1,11-L-
for the performance of the work for which this permit is `I y�1
issued (Sec. 3097, Civ. C.). SIGNED THIS �+ DAY OF_ 1470,^16 19L
OWNER OR
Lender's Name OWNERS AGENT ,
Lender's Address ADDRESS
1 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
upon the above-menu Ldproperty27 for ition purposes.
14 vo
S g ature of Pe mittee 3ote SEE REVERSE FOR EXPLANATORY LANGUAGE
COUNTY OF LOS ANGELES' l TEMPLE CITY' # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS SE 0508 9808210003
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID: SEWER / SEPTIC: .S BUILDING ADDRESS:
TR: 11454 LT: 41 EXIST OCC GRP: 4943 FIESTA AV
BLDGS. NOW ON LOT: TEMP CA 917803817
ASSESSOR INFORMATION NUMBER: CONNECTION TYPE: NEAREST CROSS STREET: LOWER AZUSA
8590-019-023 ORIGINATION: THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY
LENGTH ML TO PL: STATION: DEPTH:
TENANT: MANHOLE REFERENCE: UPPER/LOWER: ISSUED ON: PROCESSED BY: EXPIRES ON:
08/21/98 UT 08/21/99
COUNTY IMPROVEMENT NUMBER:
OWNER: TEL. NO: PLAN CHECK NUMBER: FINAL DATE FINAL BY:
TRINH TONY;LAM KELLY — JOB NUMBER:
4943 FIESTA AV TRUNK PERMIT NUMBER: .�
TEMP 917803817 ROAD PERMIT NUMBER: DESCRIPTIQN OF WORK
AFFADAVIT: NO CONNECT GUEST HOUSE TO PUBLIC SEWS
WAIVER: NO
APPLICANT: TEL. NO: EASEMENT: NO
NGUYEN (626) 918-8906-
1139 GLENVIEW RD. RECORD INSTRUMENT NBR: RECORD DATE: SPECIAL CONDITIONS:
WEST COVINA, CA HIGHWAY/STREET WIDENI;NG:—
STATE ENCROACHMENT--PERMIT—NUMBER,RM —_ ^
o(( � � Y
CONTRACTOR: TEL. NO: t�\�`'� '--FEES' AID APPROVALS DATE INSPECTOR SIGNATU
REACH CONSTRUCTION (818) 282-0042— \�� �._ U1�
419 N. ATLANTIC BLVD., #207 LIC. NO FEE DESCRIP,TTON:, QUANTITY. UOM::P AMOUNT: NEW HOUSE SEWER
MONTEREY PARK, CA 91754 6957536 �� ss \\ �(/ `2
01=FERMI%T�ISSUANCE FEE �� 27.75 CONNECT ADDITIONAL
19 CONN%ADDT�NL`BLDG(S) 1.00 EAC, 30.45 BUILDING OR WORK
ARCHITECT OR ENGINEER: TEL. N0: �/ AL\S \ 58.20
� I s SEPTIC TANK, SEEPAGE PIT
LIC. N0: d ' _.-__ AND/OR DRAIN FIELD
DRYWELL
SEWER MAP BOOK: PAGE: �I r� ( ��r� f �� �1 r����1 �� ��`il ALTER, REPAIR, SEWER OR
r
SEWAGE DISPOSAL SYSTEM
--- DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS _
SEEP. PIT CESSPOOL
GRAYWATER SYSTEM
REPORT ID: DPR266 ROUTE TO BS0508