HomeMy Public PortalAbout9933 OLIVE ST_Sewer__ WORKERS"COMPENSATION DECLARATION I ' I
I herebl.o4irm that 1 have 'a certificate Of consent to self
insure,".61"a certificate of Workers'Compensation Insurance,or 76AGOD
a'certified lsapy.thereaf,(sec. 3800, Lob C,) 924002 DPW 6180 APPLICATION FOR PERMIT ►
Policy.No. 3390111-figtpany 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
department.
Date 1-1-97 Applicant Owen Bros. Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BuuDING /� STATION' DEPTH
COMPENSATION INSURANCE ADDPEW '9933 Olive. C yr
(This section need not be:completed if the work involved by the. ' REFERENT UPPER
permit is for one hundred dollars($'100)or less.)
LOCALITY Temple City LOWER
BAREST ., - TYPE OF CONNECTION LENGTH FROM
certify that in .the performance of the work for which this CROSS ST. °,� l f / v Y CURB P.L. MA..TO P.L;
permit is issued, I shall not employ any person in any manner P.C.NO.
so as to become subject to the Workers'Compensation Laws. OWNER Owen Construction 6 .CA.IMP.NO, JOB NO.
MAIL I TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS 4275 N. Baldiwn Ave.
NOTICE. TO APPLICANT: If, after making this Certificate of CITU AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO DATE
Exemption., you should become subject to the Workers' E'1 me TEL-tv0• 443-.0078 I•
Compensation provisions of the Labor code,you must forthwith DESCRIPTION LOT NO. I
comply with such provisions at this permit shall. be doomed
i HwY..okST.wIDEN1NG
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION SIZE OF LOT NO..Of BLDGS. PERMIT NO.
I,
I hereby affirm that'I am licensed under provisions of Chapter NOW ON LOT
9 (commencing with Section .7000) .of Division 3 of the Busk
USE I' CHARGES
ness and Professions Code, ond'my license is in full force and
effect. CONTRACTOR Owen. Bros. Plumbing., Inc. I. ;CONNECtIONCHARGEFEE
License Number 231-741 tic.Class C36-2.0-16q nDOkEss d REIMBURSEMENT FEE
Contractor Owen Bros. P]d .ing 9-30-97 CITY El Monte Ca TEl.NO. 443-0078 DISTRICT NO. GROUP MAP PROCESSED BY
BK FG ot
z
STATE UC. i
❑ I am exempt under Sec, of the L.A.Co. LICENSE NO.23 1-74 1 cuassC36-2.0-16 .d'. r d' 55 •. ,
NO. DESCRIPTION OF WORK FEE
Plumbing Code ond/or5ec. of-the FINAL 13
HOUSE SEWER.CONNECTING TO DATE
B. $P. Code for the followin..g,reason PUBLIC / .Z 6_ hA1i1DAT10N3 i
SEPTIC TANK,SEEPAGE PIT'OR FINAL q pyy
Date PITS AND/OR DRAINFIELD FI 1 T L[.t?;~y
HOUSE SEWER CONNECTING TO (, i-t�.L If
PRIVATE DISPOSAL SYS y 01}L s y,
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATIONGECK a„ �: f
WORK TO HOUSE SEWER K 73,50
OVERFLOW SEEPAGE PIT,.DRAINEIELD
.1 hereby affirm that I am exempt from the Contractor's License ' EXTN.,.CESS DRY-WELL,MANHOLE / qRi(
Law for the following reason (Secton 7031:5, Bussness and Pro ALTER.REPAIR OR ABANDON HOUSE CHAINI E pGO
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. �of tll4
'is not intended or offered for sale (Section 7044, Business � sa•��� � Al � �
;and Professions Code), I OWNERS Permit i; I .222
❑.I,as owner.of the property,am exclusively contracting with AUTHORIZATIONI TOTAL FEE
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 TME ABOVE DESCRImb EXISTING DWELLING TO THE PUBLIC.SEWER.
CONSTRUCTION LENDING AGENCY i
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 1 OW ER ERS AGENT
OR polo
issued (Sec. 3097, Civ. C...).. i ADDRESS
Lender's Name I
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,
and hereby authorize representatives of .this County to enter,
Upon the above-mentioned property for inspection purposes.
Signature o Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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