HomeMy Public PortalAbout5128 ROSEMEAD BLVD_Sewer__ / �
WORKERS'COMPENSATION DECLARATION 76A642D L/,—,—"CE 808 (2-80) APPLICATION FOR PERMIT*
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 certifiedof(Se 00,Lab. C. /� , ; COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. � an
om y� _ l
❑ Certified copy is hereby furnished. FOR APPLICAN O FILL IN CONNECTION DATA
BUILDING _ ,�� STATION DEPTH
Certified copy is filed with the cou ty building i spection ADDRESS UPPER
MANHOLE REFERENCE
depa tmen LOCALITY 7� ���C LOWER
DetP Applicant- NEAREST TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss sTY. CURB P.L. M.L. TO P.L.
. �!(j /C�
P.C. NO.
COMPENSATION INSURANCE OWNER sj^f��,�� C(���� CO. I.P. NO. JOB No.
MAIL �+�
(This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. 0
by the permit is for one hundred dollars ($100) or less.) U
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE
CITY y; T.L. NO.
1 certify that in the performance of the work for which this LEGAL cr_
permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING 0
so as to become subject to the Workers' Compensation Laws. U
BLOCK TRACT STATE ENCROACHMENT w
Date Applicant NO. of BLDGS. PERMIT NO. CL
SIZE OF LOT NOW ON LOT
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' USE OF CHARGES _
Compensation provisions of the Labor Code, you must forth- BUILDINGS
with comply with such provisions or this permit shall be CONTRACTOR CV��Jjt�s ��. CONNECTION CHARGE FEE
deemed revoked.
LICENSED CONTRACTORS DECLARATION ADDRESS pr REIMBURSEMENT FEE
`
I hereby affirm that I am licensed under provisions of Chapter _ DISTRICT NO. GROUP MAP PROC sseD BY
CITY_501 EL. NO.
P.
9 (commencing with Section 7000) of Division 3 of the Busi-
C.
ness and Professions Code, and my license is in full force and LICENSE NO. CLASS
effect.
_ L�0
effect. NO. DESCRIPTION OF WORK FEE
767 �` � VALIDATION
HOUSE SEWER CONNECTING TO FINAL R"
License Number Lic.Class PUBLIC SEWER DATE
SEPTIC TANK,SEEPAGE PIT OR J
��� �j }� (�1 PITS AND/OR DRAINFIELD
Contractor Ddte j—� � LGffJJJtJ�� FINAL 6
HOUSE SEWER CONNECTING TO BY s
❑ PRIVATE DISPOSAL SYSTEM
I am exempt from the licensing requirements as I am a
CONNECT ADDITIONAL BLDG.OR
licensed architect or a registered professional engineer WORK To HOUSE SEWER
acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD r
iness and Professions Code). EXTN.,CESSPOOL,DRYWELL, MANHOLE ,
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM /
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNERS Permit
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE 3 Sv
ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIB D EXISTING DWELLING
IDI, as owner of the property, will do tfie work and the TO THE PUBLIC SEWER. G j J
structure is not intended or offered for sale (Section SIGNED THIS DAY OF N 19P
7044,Business and Professions Code). OWNER OR
OWNERS AGENT Y '(�LiL/ I/17L��/Y�l-ZI7'f/ � 2 ,,,- 2,--
• ' k�
ONSTRUCTION LENDING AGENCY ADDRESS C e c `'
I hereby affirm that there is a construction lending agency I
for the performance of the work for which this permit is G �.L G` s`t r
issued(Sec. 3097,Civ.C.).
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,
and hereby authorize representatives of this County to enter
upon th above-menti d property for inspection purposes.
1 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatu a of Permittee Date