HomeMy Public PortalAbout10560 LIVE OAK AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
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I.,hereby affirm that I have a certificate of consent to self
in�ure,�or a cert,ficate of Workers' Compensation Insurance, or 76A642D
a certified cdpy thereof (Sec 3800, Lab C ) /p POP �C/p�Y�� y FOR P9 (�RNT
Policy No 3641-93campany State Fund u-� �+u Ls u-u ,�ppr�u� u LS uvu u
❑ Certified copy is hereby furnished `����� ��tlnL�i�LS ®0����6�91L
Certified copy is Bled with the county building inspection COUNTY OF LOS ANGELES BUILDINIG AND SAFETY
department'' ABPP' INC./
Date 3-16-93 Applicant ProgrAssive,Pi»mri ng FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE-OF EXEMPTION FROM WORKERS' BUILDING 10560 Live DaLk STATION DEPTH
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work Involved by theLOCALITY Tem le Cit MANHOLE REFERENCE LOWER UPPER
permit IS for one hundred dollars ($100) or less ), TYPE OF CONNECTION
NEAREST LENGTH FROM `
I certify that in the performance of the work for which this CROSS ST 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
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT If, after imakin this Certificate Of ASSESSOR sY ^, AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
g MAP BOOK �/ PAGE PARCEc;r7O'
Exemption, you should become subject to the Workers' No OF SI_DGS
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. I
9 (commencing with Section 7000) of Division 3 Of the BuSi- ADDRESSMAIL 601 S. Figueroa St. #4650 CHARGES
ness and Professions Code, and my'license is in full force and T
effect CITY LOS An eles TEL NO CONNECTION CHARGE FEE
License Number 478794 LIC Class C-36 REIMBURSEMENT FEE
CONTRACTOR Progressive Plumbing
ControctoPrOciressiye P11A a 3/16/93. DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS - 4257 -Auction AVe. #F _ BK PG
❑ I am exempt under Sec of the L A Co CITY Baldwin Park TEL No(818)962-2428 �� ,3 1,,
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,Plumbing Code and/or Sec of the STATE p t LIC FINAL U
LICENSE NO 478/94 CLASS C-3 DATEVALIDATION
B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE �� Z
O
HOUSE SEWER CONNECTING TOFlNAL
Date PUBLIC SEWER 96� BY (,)
SEPTIC TANK SEEPAGE PIT OR W
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Signature PITS AND OR DRAINFIELD W
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING To Z
PRIVATE DISPOSAL SYSTEM D
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR i
Law for the following reason (Secton 7031 5, Buisness and Pro- WORK TO HOUSE SEWER 10
OVERFLOW SEEPAGE PIT DRAINFIELD
fessions Code) EXTN CESSPOOL DRYWEIL MANHOLE g
ALTER REPAIR OR ABANDON HOUSE AI,'C 1 q.Y
❑ 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 structure07 69 ;4t
is not intended or offered for sole (Section 7044, Business Jr.
and Professions Code) �'. t- tti ITEMS ;-;
❑ I, as owner of the property, am exclusively contracting with OWNER'S Permit $ TOTAL ,�tLF
licensed contractors to construct the project (Section 7044,
Business and Professions Code) AUTHORIZATION TOTAL FEE C1` ;�{��; 69. 0
CONSTRUCTION LENDING AGENCY I HAVE AT THISDATE 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 CHANGE 00
far the performance of the work for which this permit is -
issued (Sec 3097, Civ C ) SIGNED THIS DAY of 19_
OWNER OR �y'y
Lender's Name OWNERS AGENT 10-100-0001('�0('7ini 3/17/913
I
Lender's Addiess ADDRESS
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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 auth a representatives of this County to enter
upo abov, entioned�ropelty for ins�,onurposes3 Si nature o, erinee DaSEE REVERSE FOR EXPLANATORY LANGUAGE
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