HomeMy Public PortalAbout10558 LIVE OAK AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I hove a certificate of consent to self 6A64T DPNEt89
7
Insure, or a certificate of Workers' Compensation Insurance, or 6A6a2D
a certified copy thereof (Sec 3800, Lab C ) QppUCAIWN FOR PERNT
Policy No 3641-93Company State Fund 'pe �p0 pp
ElCertifiedcopy Is hereby furnished SEWER - SEWAGE MSPOSA L
Certified copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department ABPP INC./
Date 3-16-93 Applicant Progressive Plumbincf FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS 10558 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
h{ that In the performance O{ the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
I certify P CROSS ST El Monte Ave. Y CURB P L M L TO P L
permit is issued,,I 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
Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
ASSESSOR �/ �• AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
NOTICE TO APPLICANT If, after making this Certificate of MAPBOOK (fd (� PAGE 11�9 PARCEIT�O�
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
LICENSED CONTRACTORS DECLARATION PERMIT NO
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
ness and Professions Code, and my license Is In full force and ADDRESS 601 S. Fiqueroa St. 4650 CHARGES
effect CITY I os Angeles TEL NO CONNECTION CHARGE FEE
License Number 478794 LIC Class C-36 REIMBURSEMENT FEE
CONTRACTOR Progressive Plumbin
ConiraclorPrOC(reSSive PIS. DISTRICT NO GROUP MAP PROCESSED BY
3/16/93 -
E:1 ADDRESS 4257 Auct• BK PG I am exempt under Sec of the L A Co }
2 / '
CITYBaldwin Pa TEL No(818)962-2428 D� ✓ rguit-r a.
PlumbingCode and/or Sec of the STATE LIC C=36 FINAL U
LICENSE NO 478794 CLASS ' VALIDATION
B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE r Z
O
HOUSE SEWER CONNECTING TO - FINAL I
Date PUBLIC SEWER BY V
SEPTIC TANK SEEPAGE PIT OR W
Signature PITS AND OR DRAINFIELD 0.
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM D Z
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Low for the following reason (Secton 7031 5, Buisness and Pro- WORK TO HOUSE SEWER
fessions Code OVERFLOW SEEPAGE PIT DRAINFIELD p� r_i
•T
EXTIN CESSPOOL DRYWELL MANHOLE .
❑ 1,as Owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE ACCT
SEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the Structure 151937 X9.1.0
Is not Intended or offered for sale (Section 7044, Business
and Professions Code) TOTAL
�L,
El 1, ci owner of the property, Om exclusively contracting with �t^1L m �1LJ
licensed contractors to construct the project (Section 7044, i�I
OWNER'S Permit $
Business and Professions Code) AUTHORIZATION TOTAL FEE Q CHECK 69.30
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
I hereby affirm that there is o construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CHMGE .1311
for the performance of the work for which this permit is
Issued (Sec 3097, Civ C ) SIGNED THIS DAY OF 19_
OWNER OR7
A DOCt.1-rJ LD1 Jl 11,1
Lender's Name OWNERS AGENT
•�tv
'1 • 'v
Lender's Address ADDRESS •�LJIIT 1 Fly 8
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 a representatives of this County to enter
upon t bove ntioned operty for Inspection purposes
3/16/93
SI -lure of Flerrnittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE