HomeMy Public PortalAbout5002 GLICKMAN AVE_Sewer__ WOR•' COMPENSATION DECLARATION
I hereby affirr I have a certificate of consent to self 92-0002 DPW 3/87
insure, or a cer .of Workers'Compensation Insurance, or 76A642D
a certified co thereof(Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT
Policy No.3tD41-92 Company state Fund es
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
ki Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES RUILDING 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 5002 Glickman Ave. STATION DEPTH
(This section need not be completed if the work involved by the Temple Cit MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY L� Y LOWER
I certif that in the erformance Of the Work for Wi11Ch ih15 CROSS ST.NEAREST TYPE OF CONNECTION LENGTH FROM
Y P 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.NO. JOB NO.
MAIL
Date Applicant
ADDRESS 1103 S. San Gabriel•Blvd. #H TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after making this Certificate of CITY San Gabriel TEL.No. 286-5691 AFFIDAVIT I 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. coNrRAcroR Progressive Plumbing CONNECTION CHARGE FEE �
License Nu ber 478794 c.Class C-36 ADDRESS 4257 Auction Ave. #F REIMBURSEMENT FEE d
progressive %g. 0
Contractor Date CITY Baldwin Park" TEL.NO. 962-2428 DISTRICT NO. GROUP MAP PROCESSED BY
,(ATE LIC. � BK PG Z
❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO. 478794 CLASS C-36 �U
DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the NO. FINAL W
HOUSE SEWER CONNECTING TO J� DATE VALIDATION
B. &P. Code for the following reason PUBLIC SEWER U)
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 , T-
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER _
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,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 �•'^
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure t•;a e-' _S
is not intended or offered for sale (Section 7044, Business - 66
and Professions Code). OWNER'S Permit $ -
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed COnirOClOfS f0 construct The project (Section 7044, 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.
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 or
issued (Sec. 3097, Civ. C.). OWNERS AGENT .fir•1";,�•
ADDRESS '^•- " °'•••-� -
Lender's Name
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.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE