HomeMy Public PortalAbout5947-5947 1/2 PRIMROSE AVE_Sewer__ I
' WORKERS'COMPENSATION DECLARATION 1
I'�I he.. ?affirm that 1 have: a certificate of consent to self �1
insure; or d certificate of Workers'Compensation Insurance] or 76A647D U
Q;certified co thereof Sec. 3800, Lab C.) CE 8N,REV 1/83.
Policy`No.l -(1(1 489f.(�,pony C3A_ Tar, Co
APPLICATION FOR PERMIT
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
[ICerfified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING ANDSAFETY
department.
Date 6-14-88 Applicant Owen Rrnc• P1 ham- Tnc, O PPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' au1LDl
COMPENSATION INSURANCE ADDRESS rimrose STATION DEPTH
(This section need not be completed if the work involved by the NCF
LOCAMANHOLE REFERENCE UPPER
permit is for one hundred dollars(E.100.)or less.) NEAREST
(OWER
NEAREST TYPE OF CONNECTION LENGTH FROM i
1 certify that in the performance of the work for which this CROSS ST 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 Richard Dearth Co IMP NO. JOB NO.
MAIL
Date Applicant ADDRESS 5 94 5 Primrose. TRUNK PERMIT NO ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Temple Cj.t3nEL.No. 286-7976 AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE
Exemption, you should become subject to the Workers'' LEGAL
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 I NO OF BLDGS PERMI o
512E OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF 'y , ,� 7 ��
9 .(commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
nest and Professions Code, and my license is in full force and
effect. CONTRACTOR Owen Bros. Plumbing, Inc. CONNECTION CHARGE FEE (A e :VF�
License Number 911 741 Lic.Closs 11;36-90 ADDRESS 4265 K. Baldwin Ave. REIMBURSEMENT FEE
Contractor Owen Bros, P1112ift- 6-14-88CITY E1 Monte TEL NO. 443-0078 DISTRICT NO. GROUP MAP PROCESSED
SK PG
❑ I am exempt under Sec. of the L.A.Co. STATE LIC
p LICENSE NO. 231 741 CLASS C36-20 U�
Plumbing Code and/or Sec. of the NO DESCRIPTION OF WORK FEE FINAL //�� 0
HOUSE SEWER CONNECTING TO DATE �, VALID TION
B. &P. Code for the following reason PUBLaC sEwIR u 4 W
SEPTIC TANK,SEEPAGE PITOR
Date PITS AND/OR DRAINFIELD i FIN N
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM m
Signature CONNECT ADDITIONAL BLDG OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT.DRAINFIELD
1 hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,.DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
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
is not intended or offered for sale (Section 7044, Business s 9 9 �) n
and Professions Code). OWNER'S Permit $
dTO
#: o l
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE licensed canfractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH'THE HEREIN NAMED CONTRACT (Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER q CONSTRUCTION LENDING AGENCY 06 '+ jIhereby affirm that there is a construction lending agency SIGNED THISDAY OF 1
for the performance of the work for which this permit is OWNER OR
.
issued (See. 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,
thereby authorize rep gsentativesof this County to enter
e �br aen" n 'property for inspection purposes..
`. 6-14-88
ature of Permi ee Date SEE REVERSE FOR EXPLANATORY LANGUAGE i