HomeMy Public PortalAbout5126 ROSEMEAD BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION CE �80) � "APPLICATION FOR PERMIT
808 I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or
a certified co -qf($ec. 3800, Lab.C.) �� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Nol oinpany�,
El Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING�T' �G i/I STATION DEPTH
CRCertified copy is filed with the co my buildi inspection ADDRESS' �!/// UPPER
department. LOCALITY L� �i-z MANHOLE REFERENCE LOWER
Dated AppllCant �� �� NEAREST4 TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss sr. Z2 Y.
cuRe P.L. M.L. TO P.L.
COMPENSATION INSURANCE P.C. NO.
OWNER J �� - CO. IMP. NO. JOB NO.
MAIL
(This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO.
by the permit is for one hundred dollars ($100) or less.) AFFIDAVIT I WAIVER EASEMENT RECORD. INST R. NO. GATE 0
CITY r T.L. NO. - U
I certify that in the performance of the work for which this LEGALL
permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HW V. OR ST. WIDENING Ir
so as to become subject to the Workers' Compensation Laws. O0
BLOCK TRACT STATE ENCROACHMENT V
PERMIT N
Date Applicant NO. OF BLDGS. W
SIZNOTICE TO APPLICANT: If, after making this Certificate of USE of LOT Now oN LOT 5i v 30 �
USE
Exemption, you should become subject to the Workers' CHARGES Z
BUILDINGS
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be CONNECTION CHARGE FEE
deemed revoked. CONTRACTOR �(�s y
LICENSED CONTRACTORS DECLARATION j, REIMBURSEMENT FEE
ADDRESS
I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP MAP PROCESSED By
CITY y� TEL. NO. '- � BK PG
9 (commencing with Section 7000) of Division 3 of the Busi- ✓ J �j
C.
ness and Professions Code, and my license is in full force and Li ENSE NO.Z--3�Vpff CLASS
effect.
NO. DESCRIPTION OF WORK FEE ///���
1 .�
HOUSE SEWER CONNECTING TO /sTFINAL p�'�f r�r e VALIDATION
License Numberv ! Lic. Class PUBLIC SEWER DATE / O V
SEPTIC TANK,SEEPAGE PIT OR
^ Q' PITS AND/OR DRAINFIELD
Contracto�H C�j ZL c1,
Date .^'✓-, FINAL
_r HOUSE SEWER CONNECTING TO e�
❑ PRIVATE DISPOSAL SYSTEM BY �. �•.�
I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL L.G.SOR
licensed architect or,a registered professional engineer WORK TO HOUSE SEWER
acting In my professional capacity (Section 7051, BUS- OVERFLOW SEEPAGE PIT,DRAINFIELD /✓I
SnesS and PTOfeSS1OnS Code). EXTN.,CESSPOOL,DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM'
Lic.or Reg.No. Date
A
HOME OWNER-BUILDER DECLARATION 2 r7 Q.4 A
I hereby affirm that I am exempt from the Contractor's OWNERS Permit S `"moo o o'o o Q
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE ---2;'?
ness and Professions Code): 2 7J. 0
1 HAVE AT THIS OATS A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONN EGT THE ABOVE DESCRIBED EXISTING DWELLING
F1 1, as owner of the property, will do the work and the TO THE PUBLIC SEWER. c'o a2 J C,
structure is not intended or offered for sale (Section SIGNED THIS / L DAY OF / lam 19
7044, Business and Professions Code). OWNER OR7(/{–��— y
OWNERS AGENT
CONSTRUCTION LENDING AGENCY ADDRESS
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
L'ender'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,
and hereby authorize representatives of this County to enter
upon the above-mentione_4 property for inspection purposes.
7 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature yaPermittee Date