HomeMy Public PortalAbout4962 GLICKMAN AVE_Sewer__ WORKGD'-'r;OMPENSATION DECLARATION
I hereby affirm I have a certificate of consent to self 92-0002 DPW 3/87
insure, or a cert of Workers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT
Policy N0641-92 Company State Fund es
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Ek Certified copy is filed with thg j, ptyl dclin� inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY.
department. HHttSi YY 1NVC
Date Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS 4962 G1ickMan 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
I certifythat In the performance of the work for which this CROSSSST. Lower Azusa Rd. TYPE OF CONNECTION LENGTH FROM
p 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 µµH CO.IMP.NO. JOB NO.
MAILADDRESS 1103 S. San Gabriel Blvd. # TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant i
NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
ary 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 LOT 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 Lic.Class C-36 ADDRESS 4257 Auction Ave. #F REIMBURSEMENT FEE O
Progressive Ping. DISTRICT NO. GROUP MAP PROCESSED BY 0
Contractor Date c1Tv Baldwin Park TEL.NO. 962-2428
�1 p� �I BK PG Z
❑ I am exempt under Sec. of the L.A.Co.
STATE
NO. 478794 C osS C-36 0
�� -3 -�NO. F
Plumbing Code and/Dr Sec. of The DESCRIPTION OF WORK EE FINAL U
HOUSE SEWER CONNECTING TO DATE VALIDATION LU
PUBLIC SEWER0-
B. & P. Code for the following reason Z•-2 Z 2 try
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 SEWER
SEEPAGE FIELD
I hereby affirm that I am exempt from the Contractor's License EOTN_CCES POOL,DRYWDRAMANHOLE
Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE S
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 I Permit $
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION r TOTAL FEE
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED dCONTRACTOR BUSIneSS and PfOfe55iOn5 Code CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBCONSTRUCTION LENDING AGENCY.I hereby affirm that there is a construction lending agency SIGNED THISDAY OF -•.
for the performance of the work for which this permit is OWNER OR ,
OWNERS AGENT
issued (Sec. 3097, CIV. C.). ADDRESS
Lender's Name
Lender's Address -•• •u
I certify that ].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- ntioned property for inspection purposes.
Signature Of Per, Date SEE REVERSE FOR EXPLANATORY LANGUAGE