Loading...
HomeMy Public PortalAbout10167 LOWER AZUSA RD_Sewer__ WORKERS'COMPENSATION DECLARATION I hereby affirm that 1,-have a'certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D LLLlll a certified copy thereof (Sec. 3800, Lob C. CE BOB(REV.8/81) APPLICATION FOR PERMIT Policy No. Company ©s ❑ C rtI ie copy is hereby furnished. SEWER - SEWAGE DISPOSAL �sstifiiedde�+c�oppy�y is f��Ith the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY ApTiCant� FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' ��16MBUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS LOWER, AZUSA,TEMPLE CITY (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.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. P,B NO. I P OWNER CO.IMP.NO. JOB NO. MAIL Date Applicant ADDRESS 8819 E• GARV EY #A1 TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, after making caCITY TEL.NO.this Certificate of ROSEMEAD (818)288-1080 AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE 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 S INGLE FAMILY HOUSE CHARGES ness and Professions Code, and my license is in full force and effect. j CONTRACTOR CONNECTION CHARGE FEE NATIONAL SEeURITY 0E)NSTR...1, IV License Number 4) r Ic.Class ADDRESS REIMBURSEMENT FEE 88i9 E. GARVEY #A!Contractor 1 ��� Dae L DISTRICT NO. GROUP MAP PROCESSED BY ��-q— CITY TEL.NO. ? BK �G -�/� -: 0 ❑l am exempt under Sec. '��-'/ of the L.A.Co. LICENSE NO. 471713 TE CLASS B � �� �J (/l��J\' O NO. DESCRIPTION OF WORK Plumbing Code and/or Sec. of the FINAL VALIDATION HOUSE SEWER CONNECTING TO DATE J3. & P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date 01 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 �Q 0 fessions Code): SEWER OR DISPOSAL SYSTEM ACCT Ff4�r t A . ❑ I,as owner of the property,or my employees with wages as «rte ry their sole compensation, will do the work and the structure sM07 27•x) is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ i ITEM ❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION 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 ABOV SCRIBED EXISTING DWELLING O THE PUBLIC SEWER. t�GK 27.50 • CONSTRUCTION LENDING AGENCY , �y� I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ • for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, CIV. C.). OWNERS AGENT ADDRESS 819 F- RV E A 1,ROS AD Lender's Name Lender's Address 1 AM11a5S 1 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 r ulating Plumbing and Sewers, and hereby authorize repr ter f of t is Co ty to enter upon t above- ntione per for i pectic u,poses. ign ture of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE