HomeMy Public PortalAbout4952 GLICKMAN AVE_Sewer__ WORICFR-R'COMPENSATION DECLARATION
1 hereby affirn I have a certificate of consent to self 76A642 DPW 3/87
insure, or a cer >of Workers'Compensation Insurance, or CE 808 D
a certified o,py rnereof (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT
Policy No. �ED41-92 Company State Fund ps
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
lid Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. &BPP INC.
Date Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS 4952 Glickman Ave.
(This section need not be completed if the work involved by the Tem le Cit MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY p Y 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. OWNER Texton Construction CO.IMP.NOP.C.
JOBB NO:
NO.
MAIL
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Date Applicant ADDRESS 113 S. San Gabriel Blvd. t}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
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 µ }a
ADDRESS 4257 Auction Ave. y}F REIMBURSEMENT FEE
g
Pro ressive Plb�( o
CITY TEL.NO.
Contractor Date Baldwin Park /I
962-2428 DISTRICT NOBY. GROUP MAP PROCESSED
ATEp �1 j� BK PG � Z
El am exempt under Sec. of the L.A.Co. a ENSE NO. 478794 C ASS C-36 �Q �� j>�a �', 2
DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the NO. FINAL
HOUSE SEWER CONNECTING TO DATEo`� 4 ry VALIDATION LLI
B. &P. Code for the following reason PUBLIC SEWER co
a
SEPTIC TANK,SEEPAGE PIT OR FINAL Z
PITS AND/OR DRAINFIELD
Date BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ,
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ►
I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,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 .-},`.4-
❑ 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 $ L _, )_
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project Section 7044,
P I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO s
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
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
issued (Sec. 3097, Civ. C.). OWNERS AGENT
ADDRESS .„.
Lender's Name
Lender's Address ,, _ j"?;':_• " ,.,
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 above-mentioned property for inspection purposes.
�Sig .tur.40f ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE