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HomeMy Public PortalAbout10155 LOWER AZUSA RD_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm that I, have a certificate of consent to self insu* or a'certificate of Workers'Compensation Insurance, Or 76A642D acertified copy.thereof (Sec. 3800, Lab C.) CE 808(REV.8/81) APPLICATION, FOR PERMIT Policy No. Company ©s / El Certified copy is hereby furnished. Q q SEWER - SEWAGE DISPOSAL Certified copy is fi with the county building inspection , 6.\�COUNTY OF LOS ANGELES BUILDING AND SAFETY clar�tme . Date dj pplicant1 � Y _� FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING /� ,��LO EMPLE CITY STATION DEPTH COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work Involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) NEAREST - LOWER NEAREST - TYPE OF CONNECTION LENGTH FROM I 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 so as to become subject to the Workers Compensation Laws. JOB NO. I p OWNERT-EILx CO.IMP.NO. !OB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS AR EY Al Q NOTICE TO APPLICANT: If, after makingthis Certificate of ROSEMEAD ($1$)288-1080 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY 'TEL.NO. 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 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 SINGLE FAMILY HOUSE CHARGES ness and Professions Code, and my license is in full force and CONNECTION CHARGE FEE effect. //�) (/[�� CONTRACTOR � License NumbBr / , / IC-Class ADDRESS REIMBURSEMENT FEE �d� CU _�� � f� Contractor Date18819 E. GARVEY #A! _ DISTRICT NO. GROUP MAP PROCES CITY TEL.NO. BK PG ❑-1 am exempt under Sec. of the L.A.Co. LICENSE NO. 471713 cLA J r \- m NO. DESCRIPTION OF WORK E I Plumbing Code and/or Sec. of the FINAL VALIDATION HOUSE SEWER CONNECTING TO. DATE PUBLIC SEWER B. & P. Code for the following reason SEPTIC TANK,SEEPAGE.PIT OR FINA PITS AND/OR DRAINFIELD Dote - HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER - 1 hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE �y Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 10 fessions Code): - SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as AC�++ CT.T their sole compensation, will do the work and the structure JM7 27.50 is not intended or offered for sole (Section 7044, Business and Professions Code), OWNERS Permit $ 1 ITEMS.. ❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE �. TOTAL 27=50 licensed contractors t0 construct the project (Section 7044; I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING5 v PUBLIC SEWER. - OECK 7.50 CONSTRUCTION LENDING AGENCY 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 A 8 issued (Sec. 3097, Civ. C.). OWNERS AGENT Lender's Name ADDRESS MM_N'1f14 5/25/89 Lender's Address 3548 1 ' AM11:5 I certify that I have read this application and state that the JJ`t h7 above information is correct. I agree to comply with all County Ordinances and State Ws regulating Plumbing and Sewers, andjh�Y! e-m thori repres ntati s of this County to enter upotione opert for insp Tion p poses. c�°-_9 Ilignature of ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE