HomeMy Public PortalAbout9937 OLIVE ST_Sewer__ WORKERS'COMPENSATION DECLARATION
1 hereby affirm that 1 have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or ISA662D
a certiflpq copy thereof JSqc. 3800, Lab C.) 62-0002 DPW,6/88 APPLICATION FOR PERMIT
PQlicy"No. 3'390`11--."pany_Golden Eagle
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL '
Elcertified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment.
Date 1—J-97 Applicant Owen Bros. Plumbing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS 9937 Olive c'.r f �7 STATION DEPTH
(This section need not be completed if the work involved by the , MANHOLE REFERENCE UPPER
permit is for one hundred dollars(5100)or less.) LOCALITY LOWER
I cern that in the erformance of the work for which this
NEAREST �� o TYPE OF CONNECTION M.L.TO FROM
PL.
certify P CROSS ST. r_+�.� .f' �. �€ r' -' +Z�t''' Y. CURB P.L M.L.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 CO IMP.NO. JOB NO.
MAIL 44'2 7 5. N.B a 1 dw i n Ave. TRUNK PERMIT:NO. ROAD PERMIT NO_
Dat® Applicant ADDRESS
NOTICE TO APPLICANT: If, after .making this Certificate of CITYAFFI57k WAIVER EASEMENT RECORD.INSTR.NO. DATE
Exemption, you should become subject to the Workers' LEGAL
E1 Monte TEL.No. 443-0078
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 SIZ 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
License Number 231-7.41 Li,.Class C3.6-20-16
ADDRESS 4265 N.B aldwin Ave. REIMBURSEMENT FEE U
Contractor Owen. .Bros. Pbi%bing 9-30-97 CITY E1 Monte TEL.NO 443-0078 DISTRICrNO. GROUP MAP PROCESSED BY U
BK PG Z
El am exempt under Sec. of the L.A.Co. LICENSE No, 231-741 ASS C36.-20-16 * -``�' O
NO. DESCRIPTION OF WORK 'FEE i
Plumbing.Code and/or Sec. of the FINAL c
PURL C SEWER CONNECTING TO DATE /[. W
HOUSE SEWER
bV LIDATIONi
B. 8 P. Code for the following reason ' a
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD Ylsr>.•I Z
Date HOUSE SEWER CONNECTING TO BY
Signature PRIVATE DISPOSAL�SYSTE 33,M 73.'"•r
g CONNECT ADDITIONAL BLDG.OR s
WORK TO HOUSE'SEWER 1 ITU.
OWNER-BUILDER DECLARATION �-'i
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that f am exempt from the Contractor's.License EXTN.:CESSPOOL DRYWELL.MANHOLE I •—°
Law for the following reason (Becton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE TOTAL`!� 73''-��
fesslonS Code): SEWER OR DISPOSAL SYSTEMC.}}(a( /y d Esti
❑ 1,as owner of the property,or my employees with wages as ��(i~ -•
their sole compensation,will do the work and the structure �rt`t,+ s; 1-K)
M
s not intended or offered for sole (Section 7044, Business permit E .
and Professions Code). OWNER'S v ITO❑ I,asowner of the property,am exclusively contracting with. AUTHORIZATION TOTAL FEE *�" ;# lJ� ,/Ylicensed contractors.to construct the project (Section 7044, 1 HAVE.AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACT . °'Business and Pfofessions Code). CONNECT THF ABOVE DESCRIBED EXISTING DWELLING TO 7HE PUBLIC SEWER -� � �0'f d
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency SIGNED THIS DAY OF 1 ►
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, I
and hereby authorize representatives of this County to enter
upon the above=men oned property for inspection purposes.
ignature o. Permit-tee Date SEE REVERSE FOR EXPLANATORY LANGUAGE