HomeMy Public PortalAbout9935 OLIVE ST_Sewer__ YyORKEJRS'COMPENSATION DECLARATION
I here.0p .11.irm,t.hat 1 have a certificate of consent to self
irfsare, Or a certificate of Workers'Compensation Insurance,or 78A642D
a certified co thereof. Sec. 3800, Lab C.) 92-0002DPW6789 APPLICATION FOR PERMIT
Policy No. 139011(9mpany- 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' BUILDING �� I STATION. DEPTH.
COMPENSATION INSURANCE ADDRESS 9935 Olive
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is.for one hundred dollars($100)or less.) LOCALITY Temple Cit LOWER.
NEAREST �a • ,� r TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. tS't;�.5 � . � •�/r Ji�� X1 Y. CURB P.L.. M.L..TO P.L.
permit is issued,'I shall not employ any person in any manner
so as to become.subject to the Workers'Compensation Laws. JOB NO.
OWNER Owen Construction t ion CO.,IMP.NO. JOB 140.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS 4.275 N.B aldwin: Ave
NOTICE TO APPLICANT: If; after making this Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD..INSTR.NO. DATE
9 clry E1 Monte TEL.No. 350-03.45
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code;you must forthwith DESCRIPTION' LOT NQ HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed i
revoked. BLOCK TRACT STATE'ENCROACHMENT
NO.OF BLDGS. PERMIT'NO.
LICENSED CONTRACTORS DECLARATION s1zE of Lor NOW ON LOT ,
I hereby affirm that I om licensed under provisions of Chapter
9 (commencing with Section 7000).of Division 3 of the Busi- 'I BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACrOROwen Bros. Plumbing, Inc. CONNECTION.CHARGE FEE
License Number 231-741 Lic.Class C36-20-16 ADDRESS 4.265 N'.B aldwin. Ave. REIMBURSEMENT FEE rL
Contractor Owen Bros_.: P. 9-30-97 CITY TE.L.NO. DISTRICT NO. GROUP MAP PROCESSED BY }8
- –
STATE LIC. 1 ,r. 1 A BK PG Z
El am exempt under Sec. - of the L.A.Co. LICENSE No. 231-741 am C36-20-16 O
- �-g � n
IE
Plumbing Code and/or Sec. of the FINAL
NO. DESCRIPTION OF WORK FEE
I
HOUSE SEWER CONNECTING TO 1 i4 DATEVALIDATION W
O1.1
B. '8 F. Code for the following reason, PUBLIC SEWER SEPTIC TANK SEEPAGE PIT OR L' U)
PITS AND/OR DRAINFIELD l FINAL {{
Date HOUSE SEWER CONNECTING TO BY l Z
;I PRIVATE DISPOSAL SYSTEM I Afl'7
Signature CONNECT ADDITIONAL BLDG.OR I ACCT
a r
OWNER-BUILDER DECLARATION WORK TO.
HOUSE.SEWER A� -y'j
OVERFLOW SEEPAGE PIT,DRAINFIEID , 330 f 3.5{I
I hereby affirm that I am exempt from the Contractor's License EXTN. CESSPOOL DRYWELL,MANHOLE I # ITEMS
Law for the following reason(Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE _v •�
fessions Code): SEWER OR DISPOSAL SYSTEM
TOTAL
❑ I,as owner of the property,or my employees with wages.as +, 'r"' t j
their sole•compensation,will do the work and the structure C' " I''
is not intended or offered for sale (Section 7044, Business
and
IC
and Professions Code). OWNER'S Permit S �' CHIN,E1rr
❑ I,as owner of the property;am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed'contractors to construct the project (Section 7044, 1 HAVE'AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO C1 LJ-- � +3/ 2. 96
Business and Professions Code). .CONNECT THE:ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. ,
CONSTRUCTION LENDING AGENCY , 199 1 ALM 9 o
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.). ADD ERS.AGENT �
ADDRESS
Lender's Name
Lender's Address
1 certify that 1 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.-roperty for inspection purposes.
Signature of Permittee—� Date SEE REVERSE FOR EXPLANATORY LANGUAGE