HomeMy Public PortalAbout10562 LIVE OAK AVE_Sewer__ WORKERS' COMPENSATION DECLARATION
her by offirrQ that I have o certificate of consent to self 200051 DPW 6189
Insure!or a'ceftificote of Workers' Compensation Insurance, or 76A6420 ,
_a certified-topy thereof (Sec 3800, Lab C ) APPUCATOON FOR IT LSl1 NIr
Policy No 3641-93 Company State Fund ,Wp� gy�pp®® r� pQ pp
❑ Certified copy is hereby furnished ��vv�� ��tiv��LS ®���®�d'S1lL
® Certified copy is filed with the.co my building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department ABPPy •
Date 3/16/0 Applicant Procgresssive P1 umhing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS 10562 Live Oak
(This section need not be completed if the work Involved by the P MANHOLE REFERENCE UPPER
permit Is for one hundred dollars ($100)or less ) LOCALITY Temple Cit LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that In the performance of the work for which this CROSS ST El Monte Ave. Y CURB P L M L TO P L
permit Is Issued, 1 shall not employ any person In any manner LEGAL
Pc No
so as to become subject to rhe Workers'Compensation Laws DESCRIPTION LOT NO Co IMP NO JOB NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant ,
ASSESSOR pp// -7� .�7 AFFIDAVIT WAIVER EASEMENT RECORD INSTa NO DATE
NOTICE TO APPLICANT If, after making this Certificate of MAP BOOK plo PAGE �a f PARCEP'� 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
PERMIT NO
LICENSED CONTRACTORS DECLARATION
OWNER Starts International Calif. Inc
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Bus]- MAIL CHARGES
ness and Professions Code, and mT/license is in full force and ADDRESS 601 S. Figueroa St. #4650
effect CITY Los An^eleSTEL NO CONNECTION CHARGE FEE
License Number 478794 LIC Class 'C-36 REIMBURSEMENT FEE
CONTRACTOR Progressive Plumbing
Contractor Progressive Ply. 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 PaxkNO 818 962-2428 Oa a
Plumbing Code and/or Sec of the STATE LIC FINAL O
LICENSE NO 478794 ' CLASS C-36' DATE VALIDATION V
B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE –174 Q
HOUSE SEWER CONNECTING TO FINAL F•
Date PUBLIC SEWER BY O
W
SEPTIC TANK SEEPAGE PIT OR Q.
Signature PITS AND OR DRAINFIELD
OWNER-BUILDER DECLARATION HOUSE SEWER ETo D Z
YS
PRIVATE DISPOSSALAL SYSTEM
SYSTEMM
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR II�
Law for the following reason (Secton 7031 5, Buisness and Pro- WORK TO HOUSE SEWER
fess]ons Code OVERFLOW SEEPAGE PIT DRAINFIELD /,r.r 4 8
EXTN CESSPOOL DRYWELL MANHOLE 1t''Yt'�,..LL lI.T
❑ 1,as owner of the property,or my employees with wages as ALTER REPAIR OR ABANDON HOUSE `— y7 S.i�a L.I{
SEWER OR DISPOSAL SYSTEM 3'1 L7,
their sole compensation, well do the work and the structure �•
is not intended or offered for sale (Section 7044, Business I ITEMS
and Professions Code) cps
❑ 1,as owner of the property, am exclusively contracting with OWNERS Permit $ TOTAL 69 m 30
licensed contractors to construct the project (Section 7044, OWNER'S ��el
Business and Professions Code) AUTHORIZATION TOTAL FEE p 4
'-CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT-WITH THE HEREIN NAMED CON ACTOR TO D CHANGE ,00
I hereby offirm 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 r�I�IJ TDiJI JII7rf7p
�
r_r
Lender's Name OWNERS AGENT
Lender's Address ADDRESS 8711 1 AM 8*.43
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 S laws regulating Plumbing and Sewers,
and hereby out a representatives of this County to enter
U e abo - entioned property for Inspection purposes
3/16/93
gnature ermltiee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE