HomeMy Public PortalAbout4956 GLICKMAN AVE_Sewer__ WOR"'COMPENSATION DECLARATION
I hereby offirn I have a certificate of consent to self 92-0002 DPW 3/87
insure, or a cer �of Workers'Compensation Insurance, or 76A642D
a certifiedc,Qyty thereof (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT
Policy No. .51 41-92Cornpany State Fund es
❑ Certified 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 Pl imb i ng FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS 4956 Glickman Ave.
(This section need not be completed if the work involved by the LOCALITY Temple City MANHOLE REFERENCE LOWER
UPPER
permit is for one hundred dollars ($100)or less.)
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
so as to become subject to the Workers'Compensation Laws. OWNER Te On Cg tructjon CO.IMP.NO. JOB NO.
MAIL ' ' TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of CITY San Gabriel TEL.NO. 286-5691 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
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 Plumbin. CONNECTION CHARGE FEE
III License Number 478794 LIC.Class C=36 4257 Auction Ave. #F REIMBURSEMENT FEE O
Progressive Pl ADDRESS
g g• DISTRICT NO. GROUP MAP PROCESSED BY
Contractor Date CITY Baldwin Park TEL.NO. 962-2428 v
BK PG Z
❑ 1 under Sec. of the L.A.CO. STATE �1 9 CLLIC0
I am exempt LICENSE NO. 478794 CLASS C-36
NO. DESCRIPTION OF WORK FEE ~
Plumbing Code and/or Sec. of the FINALU
HOUSE SEWER CONNECTING TO DATE VALIDATION LU
B. &P. Code for the following reason PUBLIC SEWER �� CO
SEPTIC TANK,SEEPAGE PIT OR �
PITS AND/OR DRAINFIELD FINAL Z
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD hl
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 i
fessions Code): SEWER OR DISPOSAL SYSTEM .,,.•,.•c ,
❑ 1,as owner of the property,or my employees with wages as _!3_=f ::;D
their sole compensation, will do the work and the structure _
is not intended or offered for sale (Section 7044, Business 1 S
and Professions Code). OWNER'S Permit $ ___
El 1, TOTAL FEE I,as owner of the property,am exclusively contracting with .�
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
BUSIne55 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 a
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.
Sidnature of ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE