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HomeMy Public PortalAbout5006 GLICKMAN AVE_Sewer__ WORvcDc'COMPENSATION DECLARATION I hereby affirrr 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 copthereof(Sec. 3800, Lab C.) CE 808 Policy No3641-92 Company State Fund ©s APPLICATION FOR PERMIT ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ER Certified copy is filed with the count buildin inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY" department. ABPP �NC. Date Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS 5006 Olickman Ave. STATION DEPTH (This section need not be completed if the Work Involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY Temple Cit LOWER NEARESTTYPE OF CONNECTION LENGTH FROM` 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 clTv 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 PERMIT NO. LOT 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 Busk BUILDINGS CHARGES ness and Professions Code, and my license is in full force and bi Progressive Plumbing effect. CONTRACTOR � g CONNECTION CHARGE FEE License Number 478794 Lic.Class C-36REIMBURSEMENT FEE d ADDRESS 4257 Auction Ave. #F O Progressive P'W6 DISTRICT NO. GROUP MAP PROCESSED BY V COn1raC10 CITY Baldwin Park TEL.NO. 962-2428 BK PG Z ❑ under Sec. of theL.A.Co. STATE /I �t LIC. ,? /0l�e'a O I am exemptSL LICENSE NO.478794 CLASS C-36 -,J 0 NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the FINAL V HOUSE SEWER CONNECTING TO DATE VALIDATION W B. $P. Code for the following reason PUBLIC SEWER d Z- U) SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD BY Date HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER Poo. tl" 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, BUisness and Pro- ALTER;REPAIR OR ABANDON HOUSE ". .? :-E' fessions Code): SEWER OR DISPOSAL SYSTEM ---- 1, "I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure T - is not intended or offered for sale (Section 7044, Business 's and Professions Code). OWNER'S Permit $ AUTHORIZATION ❑ I, as owner of the property,am exclusively contracting with TOTAL FEE licensed contractors to construct the Si7044, ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO project (Section PNTRACTOR 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 issued (Sec. 3097, Civ. C.). OWNERS AGENT 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-m tioned property for inspection purposes. _Z9 Sign ure of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE