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HomeMy Public PortalAbout5000 GLICKMAN AVE_Sewer__ WORYCDC'COMPENSATION 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 rnereof (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT Policy No.3641-92 Company State Fund ©s ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL 91 Certified copy is filed with the county buildi7 inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. ABPP INC. Date Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS 5000 Glickman Ave. STATION DEPTH (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 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 subject to the Workers'Compensation Laws. P.C.NO. so as to become sub i p 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 Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR Pro ressive Plumbinq CONNECTION CHARGE FEE C-36 .{{��. } License Nu ber 478794' L;o.class ADDRESS 4257 Auction AVe• yt-F REIMBURSEMENT FEE 0 rogresslve Plumbing p DISTRICT NO. J!�� MAP PROCESSED BY 0 Contractor Date CITY Baldwin Park TEL.NO. 962-2428_ BK PG ❑ lam exempt under Sec. of the L.A.Co. STATE 478794 LILA C-36 -�� o P LICENSE NO. CLASS DESCRIPTION OF WORK FEE -9 Plumbing Code and/or Sec. of the NO. FINAL W HOUSE SEWER CONNECTING TO DATE VALIDATION B. & P. Code for the following reason PUBLIC SEWER W 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 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, Buisness 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 their sole compensation, will do the work and the structure .4 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit $ 12111 El 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE •-I,F_ 6-S — —_ licensed contractors to construct the project Section 7044, `1''" ! = — — P I ( HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. ":i_{`''•�? _ CONSTRUCTION LENDING AGENCY SIGNEDTHIS / DAY OF 19_ , ,,=1- I hereby affirm that there is a construction lending agency MIR—, l�sr_ for the performance of the work for which this permit Is OWNER OR issued (Sec. 3097, CIV. C.). OWNERS AGENTADDRESS Lender's Name I,+ U'i_iJ. _. __. 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 above- entioned property for inspection purposes. Q �4 Sign Lure of ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE