HomeMy Public PortalAbout4958 GLICKMAN AVE_Sewer__ WORK-`-OMPENSATION DECLARATION
1 hereby affirm I have a certificate of consent to self 76A642 DPW 3/87
insure, or a certi of Workers'Compensation Insurance, or CE 808 8D flsl
a certified cop thereof(Sec. 3800, Lab C.) oe
Policy No. 3E041-92company State Fund Os APPLICATION FOR PERMIT
❑ Certified copy is hereby furnished. SEWER SEWAGE DISPOSAL
:R] Certified copy is filed with IgVnJly,bdIldir7 inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. Ata N
Date Applicant—Progressive ressive PlumbingFOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS 4958 GliCkman Aye.
(This section need not be completed if the work involved by the Tem le Clt MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY p Y LOWER
NEAREST TYPE 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.C.NO.
I P OWNER Texton Construction CO.IMP.NO. JOB NO.
MAIL Date Applicant ADDRESS 111J3 S. San Gabriel Blvd. #H TRUNK PERMIT NO. ROAD PERMIT NO.
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of 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 Plumbing CONNECTION CHARGE FEE
License Number 478794 L'C.Cla55 C-36 REIMBURSEMENT FEE }
Progressiveg. ADDRESS 4257 Auction Ave. #F a
Contractor Date CITY Baldwin Park TEL.NO. 962-2428 DISTRICT NO. GROUP MAP PROCESSED BY Z
ATE �1 A BK PG Z
❑ I am exempt under Sec. of the L.A.Co. LI
LICENSE NO. 478794 CLASS C-36 1e(� 3 �
(,)
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO / DATE VALIDATION LU
B. & P. Code for the following reason PUBLIC SEWER Z_ZZ Z/ IL
SEPTIC TANK,SEEPAGE PIT OR Z
PITS AND/OR DRAINFIELD FINAL _
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
SEEPAE INFIELD
I hereby affirm that I am exempt from the Contractor's License EO TN.,OW CCESSPOOL,_DRYWEDLLAMANHOLE .00
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
I"
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 TOTAL FEE + _
❑ I,as owner of The property, am exclusively contracting with "„`°'t '`6 6
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 SIGNEDTHIS DAY OF 1
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
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- entioned property for inspection purposes.
3-3%4
Signature of ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE