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HomeMy Public PortalAbout9524 LIVE OAK AVE_Sewer__ WORKERS'COMPENSATION DECLARATION 2 DPW 3/87 I hereby affirm that I have a certificate of consent to self q2-00092-00076A64D ir!sure, or a certificate of Workers'Compensation Insurance, or CE Boa Pow yifNod clay t�iery�gf( 3800, L�N ),InS. Co. ©S PPLI TI PERMIT UU4tt55 yy o any �p� ® pp®w ® /� ❑ Certified copy is hereby furnished. SEINER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date 4-16-92 Applicant Owen Rrnc P1 rrmhi ng FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS .9524 Live .Oak This section need not be completed if the involved the UPPER ( petee worinvoveb y LOCALITY .Temple City MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or less.) NEAREST TYPE OF CONNECTION LENGTH FROM 1 certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner P.C.NO. so as 10 become subject to the Workers Compensation Laws. OWNER 11inCO.IMP.NO. JOB NO. MAIL o TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant " ADDRESS P.O." 'BOX 8 7 NOTICE TO APPLICANT: If, after making this Certificate of �y, CITY Arcadia TEL.No. 355'-.8569 AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE Exemption, you should become subject to the Workers' y 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 BLDGS. PERMIT NO.: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. CONTRACTOROwpn CONNECTION CHARGE FEE } License Number 231 741 Lic.Class 'c-3620 16— ADDRESS �-F V/2/_5 Baldwin REIMBURSEMENT FEE O DISTRICT NO. GROUP MAP PROCESSED BY V Contractor OWPn EPC)-,_ Date 4—.16-9 2 'CITY EI Monte TEL NO. 443-0078 BK PG - ❑ I am exem t under Sec. of the L.A.Co. STATE 231. 741 L'� C36=20-16 3 O P LICENSE NO. CLASS �J.•Q(P �Ea2 t�G FINAL Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE AL W HOUSE SEWER CONNECTING TO DATE VALIDATION a B. & P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR N PITS AND/OR DRAINFIELD ' FINAL ,,,•, Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM -, �.'° -' Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER'DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, BUISne55 and Pro- ALTER,REPAIR OR ABANDON HOUSE fesslons Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure "'t+_?-:., '. - r" :t is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ 24 75 ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 66, 53 licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. _ _•r. E CONSTRUCTION LENDING AGENCY u .'„ t r SIGNED THIS DAY OF 19_ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS Lender's Name 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, An4 hereby authorize representatives of this County to enter U In the above-mentioned property for inspection purposes. 'gnature of Permittee bate- SEE REVERSE FOR EXPLANATORY LANGUAGE