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HomeMy Public PortalAbout10163 LOWER AZUSA RD_Sewer__ 'WORKERS'COMPI=NSATION DECLARATION I hereby affivm that I have a certificate of consent to self insu 4 or a certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.8/81) APPLICATION FOR PERMIT Policy No. Company ©s �❑-�,,,,C_ertified copy is hereby furnished. 1 SEWER - SEWAGE DISPOSAL _Certified copy is filed with the county building inspection �'CS/ COUNTY OF LOS ANGELES BUILDING AND SAFETY Date -" pp Ic nt� ,� i FOR APPLICANT TO.FILL IN. CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS LOWER AZUSA,TEWL E C I'TY STATION DEPTH (This section need not be completed If the work Involved by The MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) NEARESY TYPE OF CONNECTION LOWER I certify that In the performance Of the work for which this CROSSSST. LENGTH FROM Y. CURB P.I. M.L.TO P.L. permit is issued, I shall not employ any person in any manner SO as to become subject to the Workers'Compensation Laws. OWNER p r� .yy CO.IMP.NO. JOB NO, MAIL. Date Applicant ADDRESS 8819 E• GARV EY 7/'A 1 TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, after makingThis Certificate of ROSEMEAD (818)288-1080 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY TEL NO. Exemption, you should become subject to the WorkersLEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT _ LICENSED CONTRACTORS DECLARATION NO.of PERMIT No. LOT SIZE OF LOT - NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the BUST- BUILDINGS SINGLE FAMILY HOUSE CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE License Num er ic.Class 'S'FTT/ �/�1 ADDRESS REIMBURSEMENT FEE ContractorD�re�G�'I' �J-•Y DISTRICT NO. GROUP MAP PROCESSED BY CITY Z TEL.NO. p yq BK ❑r)am exempt under$eC. Of The L.A.CO. LICENSE NOSTATE . 47 713 LI C. Plumbing Code and/or Sec. of the ASS B ' FINAL NO. DESCRIPTION OF WORK \ U ! HOUSE SEWER CONNECTING TO DAT VALIDATION B. & P. Code PUBLIC SEWER for the following reason SEPTIC TANK,SEEPAGE PIT OR _—� FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO 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 (Sectors 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): - SEWER OR DISPOSAL SYSTEM AMA ❑ I,as owner of the property,or my employees with wages as �P their sole compensation, will do The work and the structure 3M7 27.50 is not intended or offered for sale (Section 7044, Business ! and Professions Code). OWNER'S Permit $ /d .. ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE r� U . TOTAL 27.50 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. ' MCK 27.50 CONSTRUCTION LENDING AGENCY � I hereby affirm that there is a construction lending agency SIGNED THIS - Y OF 14_ , . elm for the performance of the work 'for which this permit is ER OR9AM &AIR ADDRESS OWN OWNERS AGENT 'DA 1 -P R EMEA issued (Sec. 3097, Civ. C.). nrynn nr�nr ` '� Lender's Name 00100."(10 1 / Lender's Address 3%2 I certify that I have read this application and state that the above information is correct. I a ree to comply with all County ordinances and State laws re luting Plumbing and Sewers, and hereby authori a ned tatives of s C my to ent r upon t above- ntioned o ert n pect rpose �- Si n ure of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE