HomeMy Public PortalAbout5012 GLICKMAN AVE_Sewer__ WOR-1—COMPENSATION DECLARATION
I hereby affirn I have a certificate of consent to self 92-0002 DPW 3/87
insure, or a cer I of Workers'Compensation Insurance, or 76A642D
a certified co the (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT
Policy No.3� 1-92 Company State Fund Os
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
® Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. ABPP INC.
Date Applicant Procfressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS 5012 Glickman 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 City LOWER
NEARESTTYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. bower 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. P.C.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
(evoked. 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
TSE OF
9 (commencing with Section 7000) of Division 3 of the BUST- 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 0
Contractor Nate CITY Baldwin Park TEL.NO. 962-2428
Progressive Pl DISTRICT NO. GROUP MAP PROCESSED BY 0
BK PG Z
❑ 1 am exempt under Sec. of the L.A.Co.
STATE
LICENSE NO. 478794 CLASS C-36 ��� 0
Plumbing Code and/or Sec. of the No. DESCRIPTION OF WORK FEEL
HOUSE SEWER CONNECTING TO DATE VALIDATION LU
B. & P. Code for the following reason PUBLIC SEWER 'Z-( U)
SEPTIC TANK,SEEPAGE PIT OR FINAL Z
PITS AND/OR SEEPAGE
PI
Date BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
SEEPAGE INFIELD
I hereby affirm that I am exempt from the Contractor's License EO TN.,OW CESSPOOL,DRYW LL,MANHOLE
Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE �-
fesslons Code): SEWER OR DISPOSAL SYSTEM
qi•. -
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 saleSection 7044, Business _ r
( i
and Professions Code). OWNERS Permit $ L I
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE ;f h
[Lj t
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTITOBusiness and Professions Code CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 1 ' _ I'h<<73w .`{'_I
for the performance of the work for which this permit is OWNER OR
OWNERS AGENT
issued (Sec. 3097, CIV. C.). ADDRESS I^.i-p'aq
Lender's Name - •• --•• •-
Lender's Address - :'I'w{ =.
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-mentioned property for inspection purposes.
Si ature o Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE