HomeMy Public PortalAbout10157 LOWER AZUSA RD_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.8/8)) APPLICATION FOR PERMIT
P '!icy No. Company Os
rl'Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
52�_;ertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
Datmd� ment. — ``y-,' sr
Applicant /0�J��')— til 1 J fir""r FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING ® 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 ($100)or less.) LOCALITY LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L.TO P.L.
permit is issued', I shall not employ any person in any manner
subject to the Workers'Compensation Laws. P.C.NO.
so as to become sub
I p OWNER TEMPLE RGLEXX• CO.IMP.NO. 108 NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of CITY AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
Exemption, you should become subject to the Workers' ROSEMEAD TEL.NO. ($�$)2$$—�Q$Q
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 SIZE OF LOT NO.OF BLDGS. PERMIT NO.I hereby affirm that I am licensed under provisions of Chapter USE OF NOW ON LOT
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. CONTRACTOR "• CONNECTION CHARGE FEE
License Number //L�c% lass ADDRESS NATIONAL SECURITY CONSTRUCT 10 REIMBURSEMENT FEE
`,. N�j/ sw os--Z��- DISTRICT NO. GROUP MAP PROCESSED BY
Contractor N��i w/tT Date CITY TEL.NO.
ROSEMEAD _ BK PG
❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO. IL ss (09 �`� 0
NO. DES RIP I F WORK F
Plumbing Code and/or Sec. of the FINAL O VALIDATION
HOUSE SEWER CONNECTING TO ...�
B. & P. Code for the following reason
PUBLIC SEWER DATE
SEPTIC TANK,SEEPAGE PIT OR FINAL g
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
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, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
feSSiOnS Code): SEWER OR DISPOSAL SYSTEM
��ss a
El 1,as owner of the property,or my employees with wages as IICYTJ
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business M07 27.51
and Professions Code). OWNERS Permit $ 1 ITEM
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE n Tl�
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A'CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO TRIAn. � til®
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLINa T9 THE PUBLIC SEWER. 4�1Lt,{ti �7�„_
CONSTRUCTION LENDING AGENCY �CHL '150
1 hereby affirm that there is a construction lending agency SIGNED THIS _DAY OF 1 4W
for the performance of the work for which this permit is OWNER A , •00
issued (Sec. 3097, CIV. C.). OWNERS AGENT
ADDRESS 5/2589
Lender's Name
Lender's Address M47 AM11*2
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 a regulating Plumbing and Sewers,
and hereby au ori repres ntat' es of This County t' enter
upon a abo - " nT oned rop for insp tion puS.S.
l/J ✓ �
I nature o ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE