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HomeMy Public PortalAbout5616 GOLDEN WEST AVE_Sewer__ + WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self ',nsurb; or,a certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.8/81) APPLICATION FOR PERMIT Policy No. 994965 Company Republic Tnde=i Y)r ©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 de iartment. Date /24/93 Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTI N FRO WORKERS' BUILDING 5616 N. GOLDENWEST STATION DEPTH COMPENSATION INSURANCE ADDRESS5��7 (This section need not be completed if the work involved by the UPPER permit is for one hundred dollars ($100)or less.) LOCALITY TEMPLE CITY CA MANHOLE REFERENCE Co O • NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. 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 JOE CAMPIONE CO.IMP.NO. JOB NO. MAIL Date Applicant ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY T le Cit TEL.N0.285_gg23 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 FRANK NIARRONE & SONS CONNECTION CHARGE FEE INC. >. License Number 397884 Lic.Class C/36 C/16 _ A. 9860 Lower Azusa Road REIMBURSEMENT FEE DISTRICT NO. GROUP MAP PROCESSED BY ContractaF-Marrone & Sons, JAie. 12/31/93 CITY El Monte TEL.NO. BK PG 7- ❑ I am exempt under Sec. of the L.A.Co. LICENSE No. 397884 CAss C 36 C 16 ,�.D� - 3 'r / L DESCRIPTION OF WORK FEE — Q� Plumbing Code and/or Sec. of the NO. FINAL VALIDATION HOUSE SEWER CONNECTING TO DATE B. & P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR g FINAL PITS AND/OR DRAINFIELD Date BY HOUSE SEWER CONNECTING TO 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;`.ACCT, fessions Code): SEWER OR DISPOSAL SYSTEM s'i t`i ' El 1, as owner of the property, or my employees with wages as 3307JL� ! Li�Ji 7ri their sole compensation, will do the work and the structure 3 I EML is not intended or offered for sole (Section 7044, Business and Professions Code). OWNER'S PermitAUTHORIZATION $ ,� -IOTA 69 - 30 ❑ I,as owner of the property, am exclusively contracting with TOTAL FEE ......... C$'IECt� Lid licensed contractors to construct the project Section 7044, ° P I ( 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. -".. CHANGE III) CONSTRUCTION LENDING AGENCY Q 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 ='1Il�Il_dI){ 16j:i�; OWNERS AGENT .3J 3 3 .4 issued (Sec. 3097, Civ. C.). ADDRESS 9Rhf1 T X-Mr- Ansa Rd El Poe x �A n, �, ji� (; ;°c6 Lender's Name e--� 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 Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. - 9-q. Signotu' of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE