HomeMy Public PortalAbout10556 LIVE OAK AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
20 0051 DPW 6/89
I hereby affurr matI 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 ) APP 0CAMN FOR P('�•RM7
Policy No 3641-93Company State Fund `Lsp' - ape ue LOuupL
❑ Certified copy is hereby furnished S�l�l�f� S�W��� ®B��®�Pwl�
KI Certified copy is filed with rh oun'ty building Inspection COUNTY OF LOS ANGELES o3UILDIG,AND,SAFETY
department AB IIC.
Date 3/16/93 Applicant Progressive Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKFRS' BUILDING r
COMPENSATION INSURANCE ADDRESS Liv# 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 TYPE OF CONNECTION LENGTH FROM
I terrify that in the performance of the work for which this CROSS ST El Monte Ave. Y CURB P t ML TO P L.
permit Is Issued, 1 shall not employ any person in any manner LEGAL PC NO
so as to become subject to the Workers' Compensation Laws DESCRIPTION LOT NO CO IMP NO JOB NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant '-
NOTICE TO APPLICANT If, after making this Certificate Of ASSESSOR p/ �y �7 AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
g MAP BOOK �O v PAGE �v PARCEI��
Exemption, you should become subject to the WorkersNo OF BLDGS
Compensation provisions of the Labor code, you must forthwith S12E 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
LICENSED CONTRACTORS DECLARATION PERMIT No
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 Busl- MAIL s 601 S. Fi eroa St. #4650 CHARGES
ADDness and Professions Code, and my'license is in full force and
effect CITY Los Angeles TEL NO CONNECTION CHARGE FEE
License Number 478794 Lic Class C-36 REIMBURSEMENT FEE
- CONTRACTOR Progressive Plumbin DISTRICT NO GROUP MAP PROCESSED BY
ContractorProgressiye Ply. 3/16/93 ADDRESS 4257 .Auction Ave. F f� z BK PG '
F] I am exempt under Sec of the L A Co CITY Baldwin Park TEL NO(818)962-2428 a
Plumbing Code and/or Sec of the STATE LIC FINAL 0
LICENSE NO 478794 CLASS C-36 DATE �� VALIDATION
B -8 P Code for the following reason NO I DESCRIPTION OF WORK FEE Q
HOUSE SEWER CONNECTING TO FINAL }-
Date PUBLIC SEWER BY (�
SEPTIC TANK SEEPAGE PIT OR LV
a
Signature PITS AND OR DRAINFIEID W
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING To D
PRIVATE DISPOSAL SYSTEM ��
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 s
fessions Code) EOVERFLOWSPEEP GE PIT DLRAINFIELD MAN OLE ��q�CCT.v
❑ I,OS owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE d{Se�iE�
' 6II J
their sole compensation, well do the work and the structure SEWER OR DISPOSAL SYSTEM JJLI '
is not intended or offered for sale (Section 7044, Business 1 1Trh S
and Prof essions.Code) TOTAL❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044, OWNER'S Permit $ CHECK
}i9 _0
Business and Professions Code) AUTHORIZATION I TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT-WITH THE HEREIN NAMED CONTRACTOR TO D CHANGE .l i!!
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 _ tJ1.N tJLf 1 1 !
Lender's Name OWNERS AGENT r-
Lender's Address ADDRESS J703 1 tf�l Vol{
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 autho ze representatives of this County to enter
upon t above7entoned property for Inspection purposes
3/16/93
S na ure P e Date SEE REVERSE FOR EXPLANATORY LANGUAGE