HomeMy Public PortalAbout10546 LIVE OAK AVE_Sewer__ WORKERS' COMPENSATION DECLARATION 20 D051 DPW 6I89
1 hereby affirm that I have a certificate of consent to self 76ABa2D
nsure, or a cp_rtlfleote'of Workers' Compensation Insurance, or
a certified copy thereof (Sec ny Lab t) /p\PPUC T O(�(I
Policy No 3641-9ompany State Fund /tel yp' !tel ,pall V,}� ll IS //��upG❑
El-Certified copy Is hereby furnished SEWER - SEWAGE ®OSP®SA L
® Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department ABPP INC./
Dote 3-16-93 Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH.
COMPENSATION INSURANCE ADDRESS 10546 Live Oak
(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
NEAREST
I certify that in the performance of the work for which this CROSS ST �, TYPE OF CONNECTION LENGTH FROM
El Monte Ave. Y CURB P l M L TOP L
permit Is Issued, 1 shall not employ any person In any manner LEGAL
so as to become subject to the Workers' Compensation Laws DESCRIPTION LOT NO P c NO
I p CO IMP NO JOB NO
Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
ASSESSORyam•/ AFFIDAVIT WAIVER EASEMENT •RECORD INSTR NO DATE
NOTICE TO APPLICANT If, after making this Certificate of MAP BOOK PAGE XP PARCL�/o1 v�
Exemption, you should become subject to the WorkersNO OF BLDGS
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF i
revoked BUILDINGS STATE ENCROACHMENT i�t
PERMIT NO t
LICENSED CONTRACTORS DECLARATION OWNER Starts International Calif. Inc. ACC-1r.• 4
I hereby affirm that I am licensed under provisions of Chapter ff•
9 (commencing with Section 7000) of Division 3 of the-Buss- MAIL -
ness and Professions Code, and my, -
r,license Is in full force and ADDRESS 601 S. Fi ueroa St. 4650 CHARGES 69."30
effect CITY Los Angeles TEL NO CONNECTION CHARGE FEE
License Number 478794 LIc Class C-36 REIMBURSEMENT FEE L
CONTRACTOR Progressive PlumbingDISTRICT NO GROUP MAP OCESSED -.'�0
Contractor - Progressive DBtlbcf. 3/16/93
ADDRESS 4257 Auction Ave. F aX PG �G•al
❑ I am exempt under Sec of the L A Co cITYBaldwin Park.. TEL No (818)962-2428 DO -�
Plumbing Code and/or Sec of the STATE CL ,91
FINAL VALIDATION Z
LICENSE NO 478794 CLASS C-36 DATE
B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE —1 0
HOUSE SEWER CONNECTING TO FINAL
Date PUBUC SEWER BY 0000-0001 ,:/17;W
SEPTIC TANK SEEPAGE PIT OR LU
M
PITS AND OR DRAWFIELD 3�7 A '
Signature 7CJ't 1 tit t v•
HOUSE SEWER CONNECTING TO
OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM Z
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031 5, Bulsness and Pro- WORK TO HOUSE SEWER
fessions Code OVERFLOW SEEPAGE PIT DR
AINFIELD
EXTN CESSPOOL DRYWEIL MANHOLE
I, as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSESEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure
is not Intended or offered for sole (Section 7044, Business e
and Professions Code)
❑ 1, as owner of the property, am eAclusively contracting with OWNERS Permit $licensed contractors to construct the project (Section 7044,
Business and Professions Code) AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO '
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER '
for the performance of the work for which this permit Is
Issued (Sec 3097, Civ C ) SIGNED THIS DAY OF 19_
OWNER OR
Lender's Name OWNERS AGENT
Lender's Address 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 Sto laws regulating Plumbing and Sewers,
and hereby out a representatives of this County to enter
Upo abov - entioned perry for inspection purposes
3/16/93
gnature of ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE