HomeMy Public PortalAbout4700 F MILLER DR_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self 92 6°z DPW e s
insure, or a certificate of Workers'Compensation Insurance, or 118 808 D L
a•ce tified cop thereof (Sec. 3800, Lab C.)
11E 808 APPLICATION FOR PERMIT
Policy No10—�4896�/�,,Pany_ :CNA .Ins. Co. �;.
ElCertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. 7
Date 9-18-94pplicant Owen Bros. Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS 4 Miller Drive �� F_&
(This section need not be completed if the work involved by thelo` '' MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY Temple Cit _ LOWER
I certifythat in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
P CROSS ST Y. CURB P.L. M.L.TO P.I.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws. P.C.NO,
OWNER CO.IMP.NO. !OB NO.
Date Applicant ADDRESS 2031 South Myrtle Avenue IL TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Monrovi4 No 359-3211 AFFIDAVIT 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
NO.OF BLDGS. PERMIT NO.
LICENSED CONTRACTORS DECLARATION SIZE OF tot Now ON Lor
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
effect CONTRACTOR
Owen Bros, Plumbing, Inc-
CONNECTION CHARGE FEE
r
License Number 231 741 Llc. Class 1736-90-76 ADDRESS 4265 N. Baldwin Avenue REIMBURSEMENT FEE O
Monte r 4O MAP PROCESSED BY 0
DISTRICT NO. GROUP
Contractor Owen Bros. Date 9-18-91 CITY El DiOnte TEL.NO. 43-0078 BK PG Z
❑ I am exempt under Sec. of the L.A.Co.
LIBK
NO. CLASS _ —
NO. DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the FINAL
HOUSE SEWER CONNECTING TO DATE VALIDATION LU
CL
B. & P. Code for the following reason PUBLIC SEWER 7 1 6 _,
SEPTIC TANK,SEEPAGE PIT OR
PITS AND'OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY /
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ,
OVERFLOW SEEPAGE PIT.DRAINFIELD
1 hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE -
r� Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE ----, -.
fessions Cade); SEWER OR DISPOSAL SYSTEM
is ❑ 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 $
1 1
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed Contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TC
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 OR
issued (Sec. 3097, Civ, C,). OWNERS AGENTADDRESS
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,
0eld1hby a i�rize representati of this County to enter
ab ertioned p ykf r inspection purposes.
' — 1
ignature of Permittee k Date SEE REVERSE FOR EXPLANATORY LANGUAGE