HomeMy Public PortalAbout10552 LIVE OAK AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby offirm'that I hove a certificate of consent to self 20-0051 DPW 6189
insure„or a certificate of Workers' Compensation Insurance, or 76A642D
a certified cdPy thereof�(Sec 3800, Lab C ) ��p���Q��OUV FOR IT EI1�IIV11��
Policy No 3641-9�ompdny State Fund ap, CC pp
❑ Certified copy is hereby furnished SEWER,- SEWAGE ®0SP®JAIL
X' Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING,AND SAFETY
departmentABPP INC. '
Date 3/16/93 Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS 10552 Live Oak
(This section need not be completed if the work Involved by the rI MANHOLE REFERENCE UPPER
permit Is for one hundred dollars ($100)or less ) LOCALITY Tent le Cit LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that In the performance of the work for which this CROSSST El Monte Ave. Y CURB PIL M L TO P L
permit is Issued, 1 shall not employ any person In any manner LEGAL
PC NO
50 OS 10 become subject to the Workers' Compensation Laws DESCRIPTION LOT NO - CO IMP NO J08 NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NOS
Date Applicant
ASSESSOR sy� AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE
NOTICE TO APPLICANT If, after making this Certificate of MAPBOOK ���� PAGE 45r/4;L PARCE
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 ST 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- MAIL
ADDRESS 601 S. F1 eroa St. #4650 CHARGES
ness and Professions Code, and m,/license is in full force and T
effect CITY LC1s Angeles TEL NO CONNECTION CHARGE FEE
License Number 478794 LIC Class C-36 REIMBURSEMENT FEE
CONTRACTOR- Progressive Plumbin
Progressive P]��. 3/16/93 DISTRICT NO GROUP MAP PROCESSED BY
Contractor ADDRESS 4257 Auction Ave. #F BK PG
_ a
❑ I am exempt under Sec of the L A Co ciry Baldwin Pa ] o -(818)962-2428 p .
Plumbing Code and/or Sec of the STATE: LIC FINAL U
LICENSE No 478794 CLASS C-36-
-3 DATE VALIDATION Z
B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE A�.� s O
HOUSE SEWER CONNECTING TO FINAL �-
Date PUBLIC SEWER BY LU
SEPTIC TANK SEEPAGE PIT OR a
Signature PITS AND OR DRAINFIELD U)
OWNER-BUILDER DECLARATION HOUSE SEWER c MG To D Z
PRIVATE DISPOSALL SYSTESYSTEM
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
fe5510n5 Code - OVERFLOW SEEPAGE PIT DRAINFIELD �.��
EXTN CESSPOOL DRYWELL MANHOLE o8
0 I, as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE „ I
a
their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM '13307 T �p� - 6.1 - ,
is not intended or offered for sole (Section 7044, Business I tTL. I
and Professions Code) _
❑ I, as owner of the property, am exclusively contracting with PerrTiIt $ TOTAL 69 -30
licensed contractors to construct the project (Section 7044, OWNER'S • ;
Business and Professions Code) AUTHORIZATION TOTAL FEE fj ''H�yE/�C� 69.3EI
{
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO RACTOR TO CHANGE .1313
1 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 41 00-[I[ft�j, 3/1{/!'
Lender's Name OWNERS AGENT
Lender's Address ADDRESS 3707 f AM 4:47
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 ouch ze representatives of this County to enter
u21
pon bov, en"a all roperty for Inspection purposes
3/16/93
S1911ature o Ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE