HomeMy Public PortalAbout4700 H MILLER DR_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self 920002 DPW 3 87
76A642D
insure, or a certificate of Workers'Compensation Insurance, or CE soe '
Pol�'r_t`jf1i�VW34�t�ereo(Sec. 3800 CNA �ri�_ Co- _ Cis APPLICATION FOR PERMIT
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
X ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant Owen Bros. Plmb FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS4700 Mill
Pr Drilli, STATION DEPTH
(This section need not be completed if the work involved by the UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY Temple (;lt MANHOLE REFERENCE LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this 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.0 NO.
OWNER wennpmpniCO.IMP.NO. JOB NO,
Date Applicant
ADADDRESS PERMIT NO, ROAD PERMIT NO.
DRESS 2031 South Myrtle Avenue AIL TR
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY MOnrOV13 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
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 BUST- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR en Rrnc_ P1 rtmh-1ntr � CONNECTION CHARGE FEE }
n License Number_ Lic.Class (�6-20-16ADDRESS 4265 N. Bald lri S7 REIMBURSEMENT FEE a
O
9-18-91 DISTRICT NO. GROUP MAP PROCESSED BY 0
'. ContractorOwen Bros. Date CITY El Monte TEL.NO. 443-0078 BK PG d�,,s � Z
❑ I am exempt under Sec. of the L.A.Co. ucEhsE No. CLASS 12-36-20-16
-
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL W
HOUSE SEWER CONNECTING TO DATE VALIDATION
�L( (
B. & P. Code for the following reason PUBLIC SEWER27 85 O.
SEPTIC TANK,SEEPAGE PIT OR .� l N
PITS AND/OR DRAINFIELD FINAL ,�-� Z
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM i
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 (Sectors 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 O
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 44 5
licensed contractors f0 COnSifUC1 the project (Section 7044, I 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 79
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C OWNERS ERS AGENT
ADDRESS _ •
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 lows regulating Plumbing and Sewers, Qy
and h reby uthorize repre entativeS of this County to enter {
Upo ih a mentio ed operty for inspection purposes. �� r
nature Of Permi, e Dater SEE REVERSE FOR EXPLANATORY LANGUAGE 47