HomeMy Public PortalAbout10550 LIVE OAK AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
heieby affirrra that I have a certificate of consent to self
20-0051 DPW 6189
InSu ;'or a certificate of Workers' Compensation Insurance, or 76A642D
o certified copy thereof (Sec 3800, Lab C ) /p1 PP��C/p\T��N FOR P�2RNT
Policy No -3641-q ompany State Fund u-u 9p0 (ry ep,�V ll IS uGU
❑ Certified copy Is hereby furnished SEWER - SEWAGE ®OSP®SAL
Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND'SAFETY
department ABPP INC.
Date 3/16/93 Applicant PmQrPssiye P1LlhLbinO FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS 10550 Live Oak STATION DEPTH
(This section need not be completed If the work Involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less ) LOCALITY Temple Cit LOWER
NEAREST
I certify that in the performance Of the work for which this CROSSST TYPE OF CONNECTION LENGTH FROM
permit is Issued, 1 shall not employ any person in any manner El Monte Ave. Y CURB P L M L TOP l
LEGAL P C NO
50 as10 become subject to the Workers'Compensation Laws DESCRIPTION LOT NO CO IMP NO JOB NO
Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT If, after makingthis Certificate Of ASSESSOR �d�/ �j ^ AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOOK Q 10 PAGE/d PARC��p�
Exemption, you should become subject to the Workers' NO OF BLDGS
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR$T WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked BUILDINGS STATE ENCROACHMENT
PERMIT NO
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter OWNER Starts International Calif. Inc.
9 (commencing with Section 7000) of Division 3 of the Busi- ADDRESS MAIL 601 S. Figueroa St. #4650 CHARGES
Hess and Professions Code, and my d
license is in full force an
effect CITY LOCA Angeles TEL NO CONNECTION CHARGE FEE
License Number 478794 Lic Class C-36 REIMBURSEMENT FEE
CONTRACTOR Progressive Plumbing
ContractoProccressive Plbcqa_3/16/93 DISTRICT NO GROUP MAP PROCESSED BY,,
ADDRESS 4257 Auction Ave. #F ' BK PG- J'�/��
❑ I am exempt under Sec of the L A Co CITY Baldwin Park TEL No $ - �D� - ! ���'f-�e/ II
Plumbing Code and/or Sec of the STATE CLICL O
FINAL VALIDATION
LICENSE NO 478794 CLASS C-36 DAZE U
B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE ? Z
HOUSE SEWER CONNECTING TO FINAL O
i Date' / PUBLIC SEWER BY V
SEPTIC TANK SEEPAGE PIT OR -W
Signature PITS AND OR DRAINFIELD n.
HOUSE SEWER CONNECTING TO
OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM D ?
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031 5, Buisness and Pro- WORK TO HOUSE SEWER i('(
OVERFLOW SEEPAGE PIT DRAINFIELD
fessions Code) EXTN CESSPOOL DRYWELL MANHOLE - p�tT i
ALTER REPAIR OR ABANDON HOUSE n3
I,as owner of the property, Or my.employees with wages as SEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure F307 69
is not Intended or offered for sale (Section 7044, Business
and Professions Code) 1 ITEMS
❑ I,as owner of the property,,am exclusively contracting with OWNERS Permit $ TOTAL m }�
licensed contractors to construct the project (Section 7044,
Business and Professions Code) AUTHORIZATION TOTAL FEE d CHECK x,9.30
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 D CHANGE .01
for the performance of the work for which this permit Is
issued (Sec 3097, Civ C ) SIGNED THIS._ DAY OF 19_ i
OWNER A i/1�iI�
Lender's Name OWNER$AGENT 13000-001-11
Lender's Address ADDRESS 87% j AM 8:47
1 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 outho representatives of this County to enter
upo above ntioned perry for Inspection purposes
3/16/93
Si ature of ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE