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HomeMy Public PortalAbout5008 GLICKMAN AVE_Sewer__ WORKED'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 coy thereof (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT Policy No. 3841-92Comp.ny State Fund ©5 ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL [R Certified copy is filed with the county buildin 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 STATION DEPTH COMPENSATION INSURANCE ADDRESS 5008 Glickman Ave. (This section need not be completed if the work involved by the Te le Clt MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY 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 subject to the Workers'Compensation Laws. P.C.NO. so as to become sub I P OWNER Texton Construction CO.IMP.NO. J08 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 Busl- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR Progressive Plumbing CONNECTION CHARGE FEE License N ber 478794 Lic.Class C-36 REIMBURSEMENT FEE 0 `frADDRESS 4257 Auction Ave. #F o resslve b Contractor g Date Baldwin Park TEL.NO. 962-2428 DISTRICT NO. GROUP MAP PROCESSED BY 0 CITY BK PG Z (�/1 LIC. ,/ El am exempt under Sec. of the L.A.Co. uT LICENSE NO. 478794 CLASS C-36 EF WORK F N TIOOE () Plumbing Code and/or Sec. of the NO. DESCRIP HOUSE SEWER CONNECTING TO FINAL DATE VALIDATION LU B. & P. Code for the following reason PUBLIC SEWER Z 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 SEEPAGE I hereby affirm that I am exempt from the Contractor's License OW EO .,XTNCESSPOOL,DRYWEDLRL,4INFIELMANHOLE Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM s•.�- ❑ 1,as owner of the property,or my employees with wages as - their sole compensation, will do the work and the structureis not intended or offered for sale (Section 7044, Business and Professions Code). OWNERpermit $ S ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 1 �53 licensed contractors to construct the project (Section 7044, 1 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-E, 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 AM,-1 is Lender's Address s" - ••""''- 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--30 ""ZZ1 Si nature of ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE