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HomeMy Public PortalAbout4950 GLICKMAN AVE_Sewer__ WORvcDc'COMPENSATION DECLARATION 1 hereby affirrr I have a certificate of consent to self 92-0002 DPW 3/87 insure, or a cerl ,of Workers'Compensation Insurance, or D CE 808 a certified copy thereof (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT Policy No. 3b41-9ompany State Fund ©s ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL - �' Certified copy is filed with the coun'tyy buildJ'ng inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. ABPP IMM / Date Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS 4950 Glickman Ave. (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 that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM I certify p CROSS ST. IAW@r 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. 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 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 BUST- BUILDINGS CHARGES 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 Contract Progressive Pll L70to Baldwin Park 962-2428 DISTRICT NO. GROUP MAP PROCESSED BY 0 CITY TEL.NO. BK PG Z or — STATE 478794 ASS C-36 , � -3 � � o ❑ I am exempt under Sec. of the L.A.Co. LICENSE No. 0 NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the FINAL W HOUSE SEWER CONNECTING TO DATE VALIDATION B. & P. Code for the following reason PUBLIC SEWER U) SEPTIC TANK,SEEPAGE PIT OR FINAL Z PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM - Signature CONNECT ADDITIONAL BLDG.OR - OWNER-BUILDER DECLARATION WORK TO HOUSE SEWEROVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the followingSecton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): reason ( 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, BusinessL 4` i and Professions Code). OWNERS Permit $ -p F - ❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE ,�, M z --. licensed contractors to construct the project (Section 7044, 1 HAVE'AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTITOBusiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCYI hereby affirm that there is a construction lending agency SIGNED THIS DAY OF , for the performance of the work for which this permit is OWNER OR OWNERS AGENT issued (Sec. 3097, Civ. C.). Ej,„sl, #whi_ „/';,•, ,,,•, ADDRESS Lender's Name F•; J. 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 entioned property for inspection purposes. a Si ature at Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE