Loading...
HomeMy Public PortalAbout4928 GLICKMAN AVE_Sewer__ WORKFQc'r'OMPENSATION DECLARATION 1 hereby affirm have a certificate of consent to self 920002 DPW 3/87 insure, or a certi iCE 808 f Workers'Compensation Insurance, or D a certified copy tnereof (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT Policy No.36z1-92 Company State Fund ©s 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. ABPP INC. Date Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS 4928 Glickman Ave. (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 Temple City LOWER NEARESTTYPE 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 so as to become subject to the Workers'Compensation Laws. P.G.NO. I P OWNER T•exton Construction .µ CO.IMP.NO. JOB NO. MAIL Date Applicant ADDRESS 113 S• San Gabriel Blvd. #H TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE 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 this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. 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 PlumbingCONNECTION CHARGE FEE License Number 478794 Lic,Class C-36 ADDRESS 4257 Auction Ave., #F REIMBURSEMENT FEE 0 ��• clrY Baldwin Park TEL.ND. 962-2428 Contractor g P Progressive DISTRICT NO. GROUP MAP PROCESSED BY (� A BK PG Z ❑ I am exempt under Sec. of the L.A.Co. STATE LICENSE NO. 478794 CLASS C-36 "�� _3 H DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the NO. FINAL W HOUSE SEWER CONNECTING TO DATE VALIDATION B. 8 P. Code for the following reason PUBLIC SEWER J SEPTIC TANK,SEEPAGE PIT OR FINAL Z_ PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM f.. Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD i 4 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 - fessions Cade): SEWER OR DISPOSAL SYSTEM •'.'`•.E•=•[ _ ❑ I,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 i E and Professions Code). OWNERS Permit $ _ ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION L55 licensed contractors 10 construct the project (Section 7044, I 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 SEWER. - �'•�-"_"" '""'-'" /•.: I: CONSTRUCTION LENDING AGENCY , ,,;-I;-}L-•,;;= "_?:'_s 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 issued (Sec. 3097, Civ. C.). OWNERS AGENT -. 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 upo �:eZabo ,entionecl property for inspection purposes. S nature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE