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Home My Public Portal About5311 GLICKMAN AVE_Sewer__ WORKERS'COMPENSATION DECLARATION ! he reby affirm that I have a certificate of consent to self a5'rssC a certificate of Workers'C ensation Insura or 76A642D y 9 002 DPW 6/88 APPLICATION FOR PERMIT a r ' cop er of(Sec. 38 ) el,:yy Compan,77 ertified copy is hereby furnished. SEWER -.SEWAGE DISPOSAL ❑ Certifie copy ! filed with the,co ly b ' in in ection COUNTY OF LOS ANGELES BUILDING AND SAFETY a ept. Dat / icant /. FOR APPLICANT TO LL N ) CONNECTION DATA CERT KATE OF EXE PTION FROM WORKERS' BUILDING l I .y vEPTH COMPENSATION INSURANCE ADDRESS V This section need not be completed if the work involved b the /� ( ll p by LOCALITY �a�•-c NHOLE REFERENCE 14-ep LOWER permit is for one hundred dollars ($100)Of less.) NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in.the performance of the work for which this CROSS S. Y. CURB P.L. M.L.TO P.L. I permit is issued, I shall not employ any person in any manner r P.C.No. so as to become subject to the Workers'Compensation Laws. OWNER / 'CO.IMP.NO. JOB NO. MAIL Date Applicant' ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, •after making this Certificate Of CITY ` AFFIDAVIT 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. . I hereby affirm that I am licensed under provisions of Chapter usE of SIZE OF LOT NOW ON LOT I 9 (commencing With Section 7000) of Division 3 of the BUSI- BUILDINGS '�L CHARGES ne(s-s-•anrofessions Cod , and y license is in full force and g�,+•�y �: �/ CO 1 CONNECTION CHARGE FEE . License�b L//CJ LIC. loss /y ADDR S' IM URSEMEN7 FEE •- � �� / - TEL J / DISTRICT NO. GROUP MAP PROCESSED BY actor ate ✓`� By r PG - STAT L ❑ I am exempt under Se of the L.A.Co. LICST _ CLASS (� Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL �d HOUSE SEWER CONNECTING TO DATE `, ,� VALIDATION Z PUBLIC SEWER B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD 1G/ 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 offirnn 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 wj fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages asi e B s their sole compensation, will do the work and the structure -1-i is not intended or offered for sale (Section 7044, Business _ and Professions Code). OWNERS Permit $ �� ®� — • property, y g TOTAL FEE l•_, _ ' ❑ I,as owner of'the am exclusively contracting with AUTHORIZATION ,. ..,,,. licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH,THE HEREIN NAMED CONI ACTOR TO 1 t?i HL_ -j 4 a '"'••a0 ' Business and ProfeSSIon S'Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. '»•IQ's-;r.I,.. i CONSTRUCTION LENDING AGENCY 3".51' 1 herebyaffirm that there is a construction lending agency SIGNED THIS DAY OF 19_ 9 9 Y for the performance of the work for which this permit is OWNER OR OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS _ Lender's Name I'=.=.¢i _QJ �;y •, -'s � 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 Plu 'bing and Sewers, &andhereb,y-aur res t orize ep entatives of t is ounty o en er ve- entioned pro ert or ! peca pu poses. Signature of P rnitfee T Date SEE REVERSE FOR EXPLANATORY LANGUAGE a u COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS SE 0508 9703210005 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA PHONE: (818) 285-0488 EXT: LEGAL ID: SEWER / SEPTIC: S BUILDING ADDRESS: TR: 10558. LT: 29 EXIST OCC GRP: 5311 GLICKMAN AV BLDGS. NOW ON LOT: TEMP CA 917803329 ASSESSOR INFORMATION NUMBER: CONNECTION TYPE: NEAREST CROSS STREET: 8585-003-008 ORIGINATION: THOMAS PAGE: 597 GRID: B4LOCALITY: TEMPLE CITY LENGTH ML TO PL: STATION: DEPTH: TENANT: MANHOLE REFERENCE: UPPER/LOWER: ISSUED ON: PROCESSED BY: EXPIRES,ON: COUNTY IMPROVEMENT NUMBER: 03/21/97 TC 03/2 /98 OWNER: TEL. NO: PLAN CHECK NUMBER: FINAL DATE FINAL BY: CODE: GEARY JAMES S;DIANE M - JOB NUMBER: f 5311 GLICKMAN AV TRUNK PERMIT NUMBER: % TEMP 917803329 ROAD PERMIT NUMBER: DESCRIPTION OF WOR AFFADAVIT: NO CONNECT NEW ADDITION TO HOUSE SEWItR WAIVER: NO APPLICANT: TEL. NO: EASEMENT: NO PHIL'S PLUMBING (818) 967-2966- RECORD INSTRUMENT NBR: RECORD DATE: SPECIAL CONDITIONS: HIGHWAY/STREET WIDENING: STATE ENCROACHMENT PERMIT NUMBER:- CONTRACTOR: TEL. NO: FEES PAID- APPROVALS DATE INSPECTOR SIGNATURE PHIL'S PLUMBING (818) 967-2966- 4412 LARKIN DRIVE C LIC. NO FEE,DESCRIPT-ION: QUANTITY: UOM:, ., AMOUNT: NEW HOUSE SEWER --��, COVINA, CA 917T_2 INSURANCE *. 01 PERMIT ISSUANCE FEE .'. 27.75 CONNECT ADDITIONAL 13;WORK3Q.HOUSE SEWER 1.00 EAC 30.30 BUILDING OR WORK ARCHITECT OR ENGINEER: TEL. NO: TOTAL FEES -.58.05 SEPTIC TANK, SEEPAGE PIT LIC. NO: AND/OR DRAIN FIELD DRYWELL SEWER MAP BOOK: PAGE: ALTER, REPAIR, SEWER OR SEWAGE DISPOSAL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER BACKFILL SEPTIC TANKS _ SEEP. PIT CESSPOOL GRAYWATER SYSTEM * ADDITIONAL DATA ON FILE REPORT ID: DPR266 ROUTE TO BS0508