HomeMy Public PortalAbout4916 ROSEMEAD BLVD_Sewer__ WORKERS' COMPENSATION DECLARATION
20-0051 DPW 6189
I hereby c,`-rm'�* I have a certificate of consent to self
insure, or arr"ertificate1--jf Workers' Compensation Insurance, or 76A642D
a certified copy thereof (Sec. 3800, Lab C.) t ®�L��°®�� � F®� PE��'y
Policy NOo_q _�-�C�ompariy em- k4em A��` �' I� �ef-e
P 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 2-�15_Applicant CL FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS —lAo STATION DEPTH
(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 �j�- LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSSST O 1 I, '2 l Y CURB P L ML TO P L
permit is issued, I shall not employ any person in any manner LEGAL P c No
so as to become subject to the Workers" Compensation Laws. DESCRIPTION LOT NO. CO IMP NO JOB NO
Date
Applicant�� BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO ,
NOTICE TO APPLICANT: If, after making this Certificate Of ASSESSOR y/ 2, AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
g MAP BDOK �[1 PAGE O PARCEL 0�
Exemption, you should become subject to the Workers' NO.OF BLDGS.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDFNING
comply with such provisions or this permit"shall be deemed USE OF
revoked. UILDINGS STATE ENCROACHMENT
PERMIT NO
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL CHARGES
ness and Professions Code, and my license is in full force and ADDRESS
effect. p CITY TEL.NO. CONNECTION CHARGE FEE
License Number .?d is Lic.Class REIMBURSEMENT FEE
/ y[� CONTRACTOR �-' �vi�_
Contractor r+'vI Y 'C L Date (!i 14-p��7 ^ DISTRICT NO GROUP MAP PROCESSED BY '
ADDRESS BK PG
p 3 }a
❑ I am exempt under Sec. of the L.A. Co. ADDCITY TEL.NO. /� S 7S�� U� a
Plumbing Code and/or Sec, of the STATE qt�j LIC, FINAL U
LICENSE NO. DATE VALIDATION z
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE O
HOUSE SEWER CONNECTING TO FINAL F-
Date PUBLIC SEWER BY V
SEPTIC TANK SEEPAGE PIT OR LU
CL
Signature PITS AND OR DRAINFIELD Fn
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Z
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK To H SEWER fl/0-
OVERFLOW SEEEPAEPAGE PIT,DRAINFIELD
fe55iOns Code): � EXTN CESSPOOL.DRYWELL.MANHOLE
El1, EWI, as owner of the property, or my employees with wages as ALTER.
ER DIS SAL SY d
their sole compensation, will do the work and the structures
is not intended or offered for sale (Section 7044, Business
and Professions Code). 170 1 a!
❑ I, as owner of the property, am exclusively contracting with { �-( -'
licensed contractors'to construct the project (Section 7044, OWNERS Permit $ Gs TOTAL 9_7
Business and Professions Code). AUTHORIZATION TOTAL FEE 1;HE_K ="_ ,=
CONSTRUCTION LENDING AGENCY I HAVE AT THIS 'DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO - r�}��X34 r
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER ® 3"ti
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). SIGNED.THIS DAY OF 19_
OWNER OR t li'e`I,"tw° i{'h t r.�''T
Lender's Name owNEas AGENT __ __ -1 :' _
Lender's Address ADDRESS i_50_ 1 ;`M, '141z
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,
(�d hereb autho Iz representatives of this County to enter
the a ave-m oned property for inspection purposes.
J Z
gnatur of Per ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE