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Home My Public Portal About9562 LOWER AZUSA RD_Sewer__ WORKERS COMPENSATION DECLARATION EiI 1 hereby affirm that I hove o certificate of consent to self 2I>-0OSt DPW 6189 u Insure or a certificate of Workers Compensation Insurance or 76AE�42D f 0 certified copy thereof (Sec 38M Lab C ) APPLICATION FOR PERMIT Policy No 4881 Company Golden Eagle ❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment Date 4-2-94 Applicant Paul Roberts FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING COMPENSATION INSURANCE ADDRESS9562 Lower Azusa 57A71°N�7f-oZ�� DEPT" (This section need not be completed If the work Involved by the LOCALITY MANHOLE REFERENCE a LOWER permit Is for one hundred dollars ($100)or less ) FROM I certify that In the performance of the work for which this CCRROOSSST d rvPE of CON TION LENGTH r CUB Pl Ml TOPL permit is Issued 1 shall not employ any person In any manner LEGAL PC NO so as to become subject to the Workers Compensation Laws DESCRIPTION LOT NO CO IMP NO JOB NO Dote—Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT If after makin this C@tilflCat@ of ASSESSOR AFFIDAVIT WAIASEMENT RECORD INSTR NO DATE g MAP SOCK PAGE PARCEL VER E Exemption you should become subject to the Workers NO OF BLDGS Compensation provisions of the Labor code you must forthwith SIZE OF LOT NOW ON LOT HWY OR S7 WIDENING comply with such provisions or this permit shall be deemed USE OF revoked BUILDINGS Residence STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER Mrs Chafsman 9 (commencing with Section 7000) of Division 3 of the Busl MAIL ness and Professions Code and my license IS In full force and ADDRESS 9 5 5 6 Lower Azusa CHARGES effect GTY a C 1 t TEL NO 798-2070 CONNECTION CHARGE FEE License Number 561193 L.c Class C-42 REIMBURSEMENT FEE ControctorP3u1 Robertftle 3-31-95 CONTRACTOR PaulRoberts DISTRICT No GROUP MAP PROCEssEDBY ADDRESS anreed Ave ^ BK PG ❑ I am exempt under Sec of the L A Co J"Op -3 �— �� d CITYRosemead TEL No 798-0725 Plumbing Code and for Sec of the STATE LIC FINAL LICENSENO 561193 CLASS C-42 DATE Z�Z5;_q VALIDATION Z B & P Code for the following reason NO DESCRIPTION OF WORK FEE ` fes/ Q HOUSE SEWER CONNECTING TO FINAL f- Dote PUBLIC SEWER O BY (� W SEPTIC TANK SEEPAGE PIT OR a Signature PITS AND OR DRAINFIELD co OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING TO = PRIVATE DISPOSAL SYSTEM I hereby affirm that I am exempt from the Contractors License CONNECT ADDITIONAL BLDG OR 1y1 Law for the following reason (Secton 7031 5 Buisness and Pro WORK TO HOUSE SEWER fessions Code) IELD E�NFLESSSPOOL DRYSEEPAGE WELL MANHOLE A!CT T ElI as owner of the property or my employees with wages as 01 �wER aEPAi SAL SvsrE �� 37.0337.03 100-V their sole compensation will do the work and the structure is not Intended or offered for sole (Section 7044 Business 1 ITEM and Professions Code) TOTAL $�� ❑ I as owner of the property am exclusively contracting with OWNERS Permit S ` -(c licensed contractors to construct the project (Section 7044 CHECK 100 L Business and Professions Code) AUTHORIZATION TOTAL FEE pp Dl CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO VL i�NSE • I hereby affirm that there is 0 construction lending agency CONNECT THE ABOVE DESCRIBED EXIS71NG DWELLING TO THE PUBLIC SEWER pop.for the performance of the work for which this permit Is Issued (Sec 3097 Civ C ) SIGNED THIS DAY OF 19_ 2 OWNER OR — � Lender S Name OWNERS AGENT *0637 1 [M Cg.,trL Lender s Address ADDRESS TUG: r J I certify that I have read this application and stole that the above Information is correct 1 agree to comply with all County or nces and State laws regulating Plumbing and Sewers d ereby authorize representatives of is County to enter po the above mentioned propert f ins n put es r , r Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE