HomeMy Public PortalAbout9309 PENTLAND ST_Sewer__ WORKERS COMPENSATION DECLARATION ' T�
I hereby affirm that I have a certificate of consent to self DISI
Insure or a certificate of Workers Compensation Insurance or
a certified copy thereof (Sec 3800 Lob,C ) CE Boa(REV B/BI) _
Policy No IV84-23r�Wany Prprnnnt. Tndamn,ty ®, APPLICATION-K
FOR PERMIT _
❑ Certified copy is hereby furnished ISEWER - SEWAGE DISPOSAL
® Certified copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date 4-19-84 Applicant Owen Bros. Plbg. FOR APPLICANT TO FILL IN CONNECTION DATA d
CERTIFICATE OF EXEMPTION FROM'MORKERS BUDDING fl! STATION DEPTH
COMPENSATION INSURANCE ADOREss
(This section need not be completed if the work involved by theU
PPER
LocnuTr ,i, d'" MANHOLE REFERENCE owRR
'permit is for one hundred dollars ($100)or less )
RFARESTYPE OF coNNEcrION LENGTH FROM
'I certify that in the performance of the work for which this aRoST ST Y CURB PL ML TOPL }
permittls Issued I shall not employ any person in any manner d
P C No
so as to become subject to the Workers Compensation Laws OWNER Pab MUrra co IMF NO TOB NO 0
h%A
Date Applicant
' [SIZE
�R3606 Rlo Hondo TRUNK PERMIT NO ROAD PERMIT NO IY
AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DALE O
NOTICE TO APPLICANT If offer making This the Work of Rosemead TECNIC 443-1579 V
Exemption you should become subject o the Workers L W
Compensation provisions of the Labor code you must forthwith Kxa Loi rq Hvn OR n WDEwNGt H
comply with such provisions or this permit shall be deemed Z
revoked V , TRACT STATE ENCROACHMENT
INC) OF BLDG5 PERMIT
LICENSED CONTRACTORS DECLARATION mT NOW aR LOT
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi S r CHARGES
ness and Professions Code and my license Is in full force and
effect I CONTRAi7OR Owen Bros. Plumbing, Inc. VRB
CHARGE HE j
License Number 911 741 Lia ,Closs C:96-9n. ADDRESS 4265 N. Baldwin Ave. NT FEE '
Contractor-Owen Bros. Pl�e 4-19-84 ' CITY El Monte TELNO 443-0078 G ' D BY
BK PG am exempt under Sec of the L ACo TE LIC
LICENSE Ft, 231,741 CLASS C36-20 �Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO VALIDATION
B 8 P Code for the following reason PUBLIC SEWERZ.SEPTIC TANK SEEPAGE%T OR%TS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO GT
PRIVATE DISPOSAL SYS
Signature , ' CONNECT ADDITIONAL BLDG OR_ Poo.DECLARATION ` WORK TO HOUSE SEWER ,
r OVERFLOW SEEPAGE PIT DRAINFIELD
I hereby affirm that I am exempt from the Contractors License ExiN CE5.5POOL DRYWELL MANHOLE '
Law for the followmg reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE ,
fesslons Code) SEWER OR DISPOSAL SYSTW
❑ 1 as owner of the property,or my employees with wages as r r 0'b 2. 3 A
their sole compensation will do the work and the structure '
is not intended or offered for sale (Section 7044 Business # 0
and Professions Code) OWNER'S Permit $ ,
❑ 1 as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE "12U Jo— - I 2t�}� 2 5 O
licensed contractors to construct the project (Section 7044 1 HAVE Ai THIS DATE A CONTRACT WITH RIE HEREIN NAMED CONTiTACTOR TO I
Business and Professions Code) , CONNECT THE ABOVE DESCRIBED METING DWELLING TO THE PUBLIC SEWER , ••'•�r� 2 1 5 0U
CONSTRUCTION LENDING AGENCY
" -
hereby affirm that there is r lending agency td '
for the performance of the workork for which
WSIGNED THIS DAY OF -19_
ch this permit is ONER 0
AGENT
}
_
issued (Sec 3097 Civ C ) II
ADDRESS ,
Lender is Name mmmmmmmmm
Lender s Address "
I certify that I have read this Opphmhon and state that the r -
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 ti '
u;�the above mentioned property for inspection purposes r, _
4�9fP0 {sets/ �{- I�—f �
T tura of Permittee Date ^—r _ SEE REVERSE FOR EXPLANATORY IAHGUAGE