HomeMy Public PortalAbout9518 LIVE OAK AVE_Sewer__ WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certified iUyo4e89tAsc.p 3800,
(SNA )Ins. CO. 92_0002 DPW 6,66 APPLICATION FOR PERMIT `�
Policy No. U 4 pony
❑ Certified copy is hereby furnished. SEWER SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date 4-15-92 Applicant Owen Bros: Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS 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 LOWER
I certify that in the performance of the work for which this FROM.
CROSS
NEARESST. TYPE OF CONNECTION LENGTH P.L.Y. CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Jim Marshall P.C.NO.
OWNER O CO.IMP.NO. JOB NO.IL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant
ADDRESS P.O. BOX H9'7
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY Arcadia TEL.NO. .355—.8569
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.of PERMIT No.
LOT
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTORngi, CONNECTION CHARGE FEE
License Number 231 741 Lic.Class G96 20 16 ADDRESS 4265 N.Baldwin Avenue REIMBURSEMENT FEE _
Contractor Owen Bros- Date 4-15-92 DISTRICT NO. GROUP MAP PROCESSED BY 0
CRY El Monte TEL.No. •443-0078 BK PG
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASSY O �
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO DATE VALIDATION (�
B. 8 P. Code for the following reason 1PUBLIC SEWER1-174
Z
SEPTIC TANK,SEEPAGE PIT OR FINAL o
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License EO TNFIOWSSPPOOL, DR AGE PIT, MNAFNHOLE
Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM r "
❑ I,as owner of the property,or my employees with wages as '�'
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business1�-
and Professions Code). OWNER'S Permit $ 24 75 7'C
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE '' - T —••--
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO I",'r�`I s r
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit is OWNER
OWNERS AGENT
issued (Sec. 3097, Civ. C.).
Lender's Name ADDRESS �I E!i•:--i3_':,'
Lender's Address
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 authorize representatives of this County to enter
X\Signature-of-Frermittee
on the above-mentioned property for inspection purposes.
Date SEE REVERSE FOR EXPLANATORY LANGUAGE