HomeMy Public PortalAbout10548 LIVE OAK AVE_Sewer__ WORKERS'COMPENSATION DECLARATION 20-0051 DPW 6/89
I hereby affikril that I have a certificate of consent to self
Insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec 3800, Lab C ) APPdICAYK0N F0Do PE"Mn 7
Policy No 3641-93compony State Fund p
[:1 Certified copy Is hereby furnished SEWER - SEWAGE ®OSP®SAL
® Certified copy is filed with the county bull Ing Inspection COUNTY OF LOS ANGELES BUILDING ANDS-AFETY
department ABPP INC.
Date 3-16-9 Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS 10548 Live Oak STATION DEPTH
(This section need not be completed If the work Involved by the m MANHOLE REFERENCE UPPER
permit Is for one hundred'dollars ($100)or less ) LOCALITY Temple Cit LOWER
certifythe performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
that m P CROSS ST El Monte Ave. Y CURB P L M L TO P 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 PC-NO
I P CO IMP NO JOB NO
Dote Appl Icanf BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT If, after making this Certificate Of ASSESSOR // AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
g MAP BOOK B76 I PAGE PAR
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 WIDFNING
comply with such provisions or this permit shall be deemed USE OF
revoked BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION ' PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER Starts International Calif. In
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL
ness and Professions Code, and m,/license Is In full force and ADDRESS
� 601 S. F1 eroa St. 5 CHARGES
effect CITY Los Angeles TEL NO CONNECTION CHARGE FEE
License Number 478794 Lic Class C-36 REIMBURSEMENT FEE
Progressive $cl+�ct. 3/16/93 CONTRACTOR Progressive Plumbincr
Contractor � T DISTRICT NO GROUP MAP PROCESSED By
resste
ADDRESS 4257 Auction Ave. F BK PG
❑ 1 am exempt under Sec of the L A Co d
CITY Baldwin Park TEL NO(818)962-2428 .f� -3 0
�Plumbing Code and/or Sec of the STATE LIcFINAL VALIDATION 0
LICENSE NO 478794 CLASS C-36 DATE
B & P Code for the following reason NO I DESCRIPTION OF WORK FEE 0
HOUSE SEWER CONNECTING TO FINAL
Date PUBLIC SEWER BY O
SEPTIC TANK SEEPAGE PIT OR Wd
Signature PITS AND OR DRAINFIELD 0.
HOUSE SEWER CONNECTING TO
OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM D a
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR 11�
Law for the following reason (Secton 7031 5, Bulsness and Pro- WORK TO HOUSE SEWER r r
fessionS Code) OVERFLOW SEEPAGE PIT DRAINFIELD �` i nY
EXTN CESSPOOL DRYWELL MANHOLE
❑ 1,as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE ��
their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM 3307 69—M
Is not Intended or offered for sale (Section 7044, Business 1 1TEMS'
and Professions Code)
❑ 1,as owner of the property, am exclusively contracting with TOTAL 69 -30
licensed contractors to construct the project (Section 7044, OWNERS Permli $ CHECK 69.30Business and Professions Code) AUTHORIZATION TOTAL FEE ` Q lj},{'r t;
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEo CONT ACTOR TO D CHANGE •00
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_ Z -7/9'f '
OWNER OR 0000-0001 til/ 1 f f�:
Lender's Name OWNERS AGENT
Lender's Address ADDRESS 3705 1 AN 3:46
1 certify that I hove 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 author) representatives of this County to enter
upon t bove- - boned pro rty for Inspection purposes
3/16/93
SI Lure Of P2rmittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE