HomeMy Public PortalAbout9324 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 certifiedfyWylhe�g 4t.an800, Lab C„�A Ins. Co. 92-0002 DPW 6/88 APPLICATION FOR PERMIT
Policy No. 11.11 UU44ZL5577 pony t,
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
{] Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date _Applicants C1s.Tan Rrnc Plm FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BuaDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS 9321 Lower
(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 Temple Cit LOWER
I certify that In the performance of the Work for which this 1 NEAREST ST. TYPE OF CONNECTION LENGTH FROM
CROSS
permit is issued, 1 shall not employ any person in any manner v_ arae P.L. V,,L,TO P.I.
so as to become subject to the Workers'Compensation Laws. " P.C. No.
OWNER CD.IMP.NO. JOB NO.
MAIL1
Date Applicant
°� DDRESS 2031. South Myrtle TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after makingthis Certificate of Monrovia AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATF
ary TEL.No. 359-3211
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
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
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 -
CONNECTION CHARGE FEE
effect. C36-20-16 CO
License Number 231 741 LIC.CIaSSADDRESS 4265 N. Baldwin Avenup REIMBURSEMENT FEE
O
Contractor Owen Bros, Date 9-18-91 CITY El Monte TEL.NO. 443-0070 DISTRICT NO. GROUP BK MAP PG '-PROCESSED BY '.0
❑ I am exempt under Sec. _._of the L.A.Co. STATE 231 741 LIC C36-20-16 r �j
P LICENSE NO. CLASS s �y�( ,tom '' ,<...=^x.", ^;�
NO. DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the FINAL ftp.
1 FHOUSE SEWER EWER CONNECTING TO 27 $r) DATE rf VALIDATION �
B. &P. Code for the following reason PUBLIC SEPTIC TANK,SEEPAGE PIT CN2
FINAL
PITS AND/CR CONNECTING
Date ROUE SEWER CONNECTING TO By
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE EWER
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
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit $ 16 50
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 44 35
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.
CONSTRUCTION LENDING AGENCY
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 OWNERSAGENT
issued (Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
Lender's Address
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 laws regulating Plumbing and Sewers,
edeby au. c�rize represent es of this County to enter
nlioned o r, for inspectionpuurposssess.
iJ !s
ignature of Permittees, Dae SEE REVERSE FOR EXPLANATORY LANGUAGE