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HomeMy Public PortalAbout4918 GLICKMAN AVE_Sewer__ WORKFvc'rOMPENSATION DECLARATION I hereby affirm have a certificate of consent to self 92-0°02 DPW 3/87 insure, or a certit if Workers'Compensation Insurance, or E 808D C a certified copy thereof(Sec. 3800, Lab C.) 0B APPLICATION FOR PERMIT Policy No.3641-92 Company State Fund ©: ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ® Certified copy is filed with the county bu'Id'ng inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. ABPP IlVC. l Date Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS 4918 Glickman Ave. STATION DEPTH (This section need not be completed if the Work involved by theMANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY Temple City LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Lower Azusa Rd. Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner P.C.NO. so as to become subject to the Workers'Compensation Laws. OWNER Texton Construction ��{{ CO.IMP,NO. JOB NO. MAILDate Applicant ADDRESS 113 S• San Gabriel Blvd. ytH TRUNK PERMIT NO. ROAD PERMIT NO. AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after. making this Certificate of CITY San Gabriel TEL.No, 286-5691 Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or thi's permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.of PERMIT No. LOT SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR Progressive Plumbing CONNECTION CHARGE FEE License Nu` 47�" Lic.Class— C36 ADDRESS *257 Auction Ave. #F REIMBURSEMENT FEE O Contractor ProCr , . Baldwin Park DISTRICT NO. GROUP MAP PROCESSED BY U CITY TEL.NO. 962-2428 BK PG Z ❑ I am exempt under Sec. of the L.A.Co. uTCENSE NO. 478794 CLASS C36 �Q H NO. DESCRIPTION OF WORK FEE - U Plumbing Code and/or Sec. of the FINAL LU HOUSE SEWER CONNECTING TO DATE VALIDATION IL B. & P. Code for the following reason t PUBLIC SEWER ZE t+ Z` \/ co Z SEPTIC TANK,SEEPAGE PIT OR FINAL Date PITS AND/OR DRAINFIELD BY — HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature - CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE - Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fesslons Code): SEWER OR DISPOSAL SYSTEM _ Ls o ••L ❑ 1,as owner of the property,or my employees with wages as _ their sole compensation, will do The work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $c;2 = ❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 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 IC CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which this permit is OWNER OR OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS Lender's Name 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, and hereby authorize representatives of this County to enter u�the4ofFfermittee ntioned property for inspection purposes.3 6 z Date SEE REVERSE FOR EXPLANATORY LANGUAGE