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HomeMy Public PortalAbout5014 GLICKMAN AVE_Sewer__ WORT-'`:OMPENSATION 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 certifie ppxx th reof(Sec. 3800, Lab C.) CE BOB APPLICATION FOR PERMIT Policy No� �2 Company State Fund ©s ElCertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with the county build' g inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. MP INC. f Date Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS 5014 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 Cit LOWER-] NEARESTTYPE 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 P.C.NO. 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 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 Progressive Plumbing CONNECTION CHARGE FEE License Number 478794 Lic.Class C-36 ADDRESS 4257 Auction Ave. #F } REIMBURSEMENT FEE d O Progressive Plbg DISTRICT NO. GROUP MAP PROCESSED BY 0 Contractor bate CITY Baldwin Park TEL.NO. 962-2428 BK PG Z El am exempt under Sec. of the L.A.Co. STATE 8 /I CL p P LICENSE NO. 47079`-3 LIC. C-36 �,�j� � � _��. _�_ ~ Plumbing Code and/or Sec. of the No. DESCRIPTIONOF'WORK FEE FINAL U HOUSE SEWER CONNECTING TO DATEVALIDATION w PUBLIC SEWER a. B. & P. Code for the following reason Z In 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 01111.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 5;'{ fessions Code): SEWER OR DISPOSAL SYSTEM -„ ❑ I,as owner of the property,or my employees with wages as1'.•_• their sole compensation, will do the work and the structure - is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit $ ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE _ I`°I licensed contractors 10 construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY =':•4; , _ I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19Boo. for the performance of the work for which this permit is OWNER OR Q 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 "-• •- sit# _„�: 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. Sig ature of ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE