HomeMy Public PortalAbout4938 GLICKMAN AVE_Sewer__ WORKFDC'I-OMPENSATION DECLARATION
I hereby affirm have a certificate'of consent to self 92-0002 DPW 3/87
insure, or a certii if Workers'Compensation Insurance, or 76A642D
a certified T 2hergp (Sec. 3800, Lq�C.) Fund O5808 APPLICATION FOR PERMIT
r
Policy No. 31741 y pay
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
® Certified copy is filed with th c unty building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. �AB°PP INC.
Date Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS 4938 Glickman Ave. 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.) LOCALITY Temple Cit LOWER
NEAREST Lower Azusa Rd. TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. 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.
MAIL Date Applicant ADDRESS 1103 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 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
I ness and Professions Code, and my license is in full force and
effect. CONTRACTOR Progressive Plumbing CONNECTION CHARGE FEE
>_License Number 478794 Lic.Class C-36 ADDRESS 4257 Auction Ave. #F REIMBURSEMENT FEE O
Progressive Plba �I DISTRICT NO. GROUP MAP PROCESSED BY ()
Contractor Bate CITY Baldwin Park TEL.NO. 962-2428 BK PG Z
❑ 1 am exempt under Sec. of the L.A.Co. ATE
uT LICENSE NO. 478794 LIC.
ASS C-36
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL W
HOUSE SEWER CONNECTING TO / O� DATE VALIDATION
B. & P. Code for the following reason PUBLIC SEWER (J l _ � CD
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL n '{ Z
,Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION IWORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License EFIELD
TNO FLOW SEEPAGE CESSPOOL,DRYWELL,MANHOLE , _.
Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE „
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ 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
and Professions Code). OWNERS Permit $
AUTHORIZATION
❑ I,as owner of the property, am exclusively contracting with 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 SEWER.
CONSTRUCTION LENDING AGENCY - -•.'v,.»:; :R
_
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 z ;;;spa_ •..,
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
upon the abov -mentioned property for inspection purposes.
—aa 336 -
Date SEE REVERSE FOR EXPLANATORY LANGUAGE