HomeMy Public PortalAbout9945 LOWER AZUSA RD_Relocation__ • r,W�kK�RS',COMPENSATION,DECLAR�ATION CE 806 2 80) APPLICATION FOR PERMIT {�
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that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL u
,tura, or a certificate of Workers'Compensation Insurance,or
a cert feed copy
0489 f Sec 3800,Lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No pang CNA Tn N- Cn_
Certified copy Is hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING STATION DEPTH
Certified copy Is filed with the county building Inspection ADDRESS7. UPPER
de artment MANHOLE REFERENCE LOWER
LOCALITY
Date Applicant�eLfln Bros. Plh�. NEAREST TYPE OP CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST Y CURB P L M L TOP L
COMPENSATION INSURANCE PC No
/ OWNER G. L. Kaplan Const. Co IMP No Joe No
/ MAIL
(This section need not be Completed if the work involved l ADDRESS 9 170 E. Las Tunas TRUNK PERMIT NO ROAD PERMIT NO d
C
by the permit is for one hundred dollars ($100) or less.) CL
CITY Temple TEL NO APPIDAVIT WANER HAY®AGNT RECORD INSTR NO DATE
I certify that in the performance of the work for which this LEGAL
permit Is issued, I shall not employ any person in any manner DESCRIPTION LOT No HWY OR ST WIDENING
so as to become subject to the Workers'Compensation Laws 0
BLOCK TRACT STATE ENCROACHMENT
Date Applicant No OF BLD GS PERMIT NO W
NOTICE TO APPLICANT If, after making this Certificate of SIZE OF LOT NOW ON LOT
Exemption, you should become subject to the Workers' USE OF CHARGEE Z
Compensation provisions of the Labor Code, you must forth- BUILDINGS _
with comply with such provisions Or this permit shall be �/ CONTRACTOR Owen Bros. Plumbing, Inc. CONNECTION CHARGE FEE
deemed revoked
LICENSED CONTRACTORS DECLARATION ADDRESS 4265 N, BaldW1n AVp,
REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter 018TIlICT NO GROUP MAP P 6621190 BY
CITY 191 Monte TEL NO 443-0078 •K .G
9 (commencing with Section 7000)of Division 3 of the Busi- CLASS
r ��
ness and Professions Code,and my license is in full force and �( STATEisE No LIC
✓,Qv
effect NO DESCRIPTION OF WORK FEE
231 74 1 C36-20 HOUSE SEWER CONNECTING TO _FINAL VALIDATION
License Number Lic Class PUBLIC SEWER `— DATE
SEPTIC TANK.SQQPAGS PIT OR
Owen Bros. 9-12-88 PITS AND/OR DRAINFIQLD
Contractor Date FINAL
PRIVATE
E DISPOSAL
CONNECTING TO BY $0 9 9.7 A
❑ PRIVATE DISPOSAL SYSTEM
I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL SLOG OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,ORAINFIELO
loess and Professions Code # • •'• • Q
BXTN.CESSPOOL.DRYWELL,MANHOLE ' • * 27.50
ALTS R.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic or Reg No Date • • 1 7 7.5 06
HOME OWNER-BUILDER DECLARATION I Q 2 6A-8 8
I hereby affirm that I am exempt from the Contractor's OWNER'S Permit f
License Law for the following reason (Section 7031 5, Busi- AUTHORIZATION TOTAL FEE 1417
ness and Professions Code) 1 HAVE AT THIS DATA A CONTRACT WITH THE HEREIN NAMED CON-
OTRACTOR TO CONNECT THEE ABOVE DESCRIBED EXISTING DWELLING
I, as owner of the property, will do the work and the TO THE PUBLIC SEWER
structure is not Intended or offered for sale (Section SIGNED THIS DAY OF to
7044,Business and Professions Code) OWNER OR
OWNERS AGENT
CONSTRUCTION LENDING AGENCY ADDRESS
I hereby affirm that there Is a construction lending agency
for the performance of the work for which this permit Is
Issued(Sec 3097,Civ C)
Lender's Name
Lender's Address
I certify that i have read this application and state that the
above information is correct 1 agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
an hereby authorize repres tatives of this County to enter
It
-menti ned i
arty for inspecton purposes -
9 I Z-88 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per ee Date