HomeMy Public PortalAbout9939 OLIVE ST_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self
ihsurd, or o.cert.ificate of Workers'Compensation Insurance,or, 70A60120 '
o.certifipd cop. thereof:(Sec. 3800, Lab C.) 92-0002 DPW 9199 ������ �� � FOR PERMIT
No, 3YI901`1-�Ip,pany GOlde:n Eagle ' '
11 Certified copy is hereby furnished. SEWER - SEWAGE. DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES j BUILDING AND SAFETY
department.
I
Date 1-1-97 .Applicant Owen Bros lu bing FOR APPLICANT'TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS` BUILDINGSTATION DEPTH
COMPENSATION INSURANCE ADDRESS 9939 Olive 7' '
(This section need not be completed if the Work involved by the MANHOLE REFERENCE JUPPE
permitis for one hundred dollars($100)or less.) LOCALITY T`em 1e Cit y performance of the work for which this NEAREST ,p( TYPE OF CONNECTION LENGTH FROM
I certlf that 'In th@ CROSS ST. e�.,,agO�S /j /��I.7 !S Y. CURB P.L. M,l.TO P..L:permit is issued, I.shall not employ any person in any mannerP.C..NOso os to become subject to the Workers'Compensation Laws. OWNER. Ow2n C.OI1StrUC.itOn Co.IMP.NO. .LOB No.
MAIL TRUNK PERMIT NO, ROAD PERMIT NO.
DataApplicant ADDRESS 4275 N.B al'dwin Ave. AFFIDAVIT WAIVEREASEMENT RECORD.INSTR.NO
NOTICE TO APPLICANT; If, after making this Certificate of cin El Monte CarEL.No. 350=0345 I
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code,you must forthwith •.DESCRIPTION LOT NO. H.WY...OR'ST.WIDENING
comply with such provisions or this permit shall be deemed r
revoked. BLOCK TRACT .STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATIONNO.OF BLDGS.. PERMIT NO.
'
I hereby affirm that I am.licensed under provisions.of Chapter SIZE OF LOTNOW ON LOT
USE OF
9 (commencing w.`ith Section 7000) of Division 3 of the Busi- USE
CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACOiowen Bros. Plumbin.f, Inc. CONNECTION CHARGE FEE:
License Number. 231-741 Lic.Class C36-20-16 „ADDRESS 4.265 N. Baldwin Ave.
REIMBURSEMENT FEE
Contractor Owen Bros. ItaL3iabinf; 9-3.0-97 ,aT\ E1 Monte TEL.NO. 443-OO7S DISTRICT NO. GROUP MAP J.PROCESSED BY
_cLSK PG Z
Eli am exempt under:Sec. _of the L.A.Co.
STC.
NSE No. 231-741 cuss C36-20-1.6
j
Plumbing Code and/or Sec.. of the NO. DESCRIPTION OF WORK FEE '.FINAL
HOUSE SEWER CONNECTING TO VALIDATION
i DATE W
B. &P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR z
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY f
Signature PRIVATE DISPOSAL SYSTEM
9
OWNER-BUILDER DECLARATION CONNECT ADDITIONAL,BLDG.OR ® y
WORKTO'HOUSE:SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD 9�y
I hereby affirm that 1 am exempt'from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
.Law for the following reason (Becton:7031.5, BUisneSs and Pro- ALTER,REPAIR OR ABANDON HOUSE I: [�
fessions Code): SEWER OR DISPOSAL SYSTEM .ACICT n C+'
❑ I,as owner of the property,or my employees-with wages as 36393 il.D t
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Businessf JTMI
and Professions Code). OWNER'$ Permit T �, ,
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE Ti_T1_ '`� `g" 1
7 .J t•
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO rI 4!n
Business and Professions Code'). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TOTHE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ) St
I hereby affirm that there is a construction. lending agency SIGNED THIS DAY OF
for the performance of the work for which this permit is OWNER OR I
OWNERS issued (See. 3097, Civ. C.,). ADDRESS AGENT I U C�01 3/ 8/96
Lender's Name
jj
Lenders Address I
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, I
and hereby authorize representatives of this County to enter 1 It
upon the above-mentioned property for.'inspection purposes. 1
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE