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HomeMy Public PortalAbout5016 GLICKMAN AVE_Sewer__ WORYcoc''"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 certified cop --of (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT Policy No364�1-92 Company_ State Fund ©s ❑ 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. Y' Date Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS 5016 Glickman Ave. (This section need not be completed if the work involved by theLocALlry Temple City MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Lower Azusa Ave. 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 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 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 O Progressive Plb�. DISTRICT NO. GROUP MAP PROCESSED BY 0 Contractor ate CITY Baldwin Park TEL.NO. 962-2428 BK PG Z ❑ I am exempt under Sec. of the L.A.Co. aCENSE NO. 478794 CLASS C-36 NO. DESCRIPTION OF WORK FEE W16ozoge 2,49— Plumbing Code and/or Sec. of the � FINAL U HOUSE SEWER CONNECTING TO DATE VALIDATION Lu B. & P. Code for the following reason PUBLIC SEWER a- 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 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 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 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the7044 i ect ro (Section , °I"3 )- = µ=• P J ( 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. ^;?�^,�••+j ; ; CONSTRUCTION LENDING AGENCY C. I herebyaffirm that there is a construction lending agency SIGNED THIS DAY OF 19_ 9 9 Y OWNER OR for the performance of the work for which this permit is OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS Lender's Name il• )I"_r ).i.^ " _._. ,� Lender's Address :! � ry i,rs."- 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. Sig ature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE