Loading...
HomeMy Public PortalAbout10165 LOWER AZUSA RD_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self In.w� 'a certificate of Workers'Compensation. 76A6421)e, or sation.Insurance, or q"certified Copy thereof (Sec. 3800; Lab C.) CE BDB(REV.8/81 APPLICATION, FOR PERMIT "Policy No. Company ©s ❑ Certified copy is hereby furnished. Q , SEWER - SEWAGE DISPOSAL �ertified copy is d with th(e�couMy bbilldiing�ns-pe�ction / COUNTY OF LOS ANGELES BUILDING AND SAFETY Date" �Cpplicant/r r`•f f(DAIS AIM— �-� r / FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS LOWER AZUSA,TEMPLE CITY STATION DEPTH This section need not be completed if the work involved b the UPPER ( P Y - MANHOLE REFERENCE LOWER LOCALITY permit.is for one hundred dollars.($100) Or less.) 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.I.TO P.L. permit is issued, I shall not employ any person in any mannerpal P.C.NO, so as to become subject to the Workers' Compensation Laws. OWNER AMPLE ROLEXX INVESTMENT CO.IMP.NO. JOB NO. MAIL s ADDRESS 881 9 E. GARVEY nA1 - TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant p Q pp NOTICE TO APPLICANT: If, after makingthis Certificate of ROSEMEAD (S1S)28S— S IVER EASE AFFIDAVIT WAMENT 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 NO.OF BLDGS. PERMIT NO. LICENSED CONTRACTORS DECLARATION SIZE OF'LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF SINGLE FAMILY HOUSE 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. 1 + - CONTRACTOR CONNECTION CHARGE FEE License Numbe / ���Lis ADDRESS NATIONAL SECURITY WNSTRUGTio REIMBURSEMENT FEE 0 �/ t CO ntra CtOf/V Date ` '"l O DISTRICT NO. GROUP MAP PROCESSED BY CITY Z MEAD TEL.NO. tom/ BK PG ^1 am exempt under Sec. of the L.A. 80 Co. CCCJJJ LICENSE NO. 47 17 1J LIC. 8 �J , / 0 NO. DESCRIPTION OF WORK F ~Plumbing Code and/or Sec. of the FINAL VALIDATION Ma HOUSE SEWER CONNECTING TO DATE B. 8 P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR FI g PITS AND/OR DRAINFIELD Date BY HOUSE SEWER CONNECTING TO e PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR ► OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER n I hereby affirm That I am exempt from the COn}raC1Of OVERFLOW SEEPAGE PIT,DRAINFIELD 5 LiCenSe EXTN.,CESSPOOL,DRYWELL,MANHOLE 1V Law for the following reason (Sefton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code):• SEWER OR DISPOSAL SYSTEM i AGGT.Y ❑ I,as owner of the property,or my employees with wages as c� their sole compensation, will do the work and the"structure ��.,..,..... �7��V is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit $ 1 ITEMS ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION 1, TOTAL FEE ~~ '.,.:.__...: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.^n 01ECK. 27.50 CONSTRUCTION LENDING AGENCY C19 *pie iL� I hereby affirm that there is a construction lending agency SIGNED THISDAY 19_ , �(�I for the performance of the work for which this permit is OWNER OR Ady OWNERS AGENT .. .. . ..... . issued (Sec. 3097, Civ. C.). P t 5,25/89 ADDRESS 1 �J Lender's Name 0000 Lender's Address 3MI 1 AM11s54 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 aws regulating umbing and Sewers, and hereby authori representatives f this County to enter upon he abov -m Toned pr erty f r 'nspection p poses. nature of P mittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE