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HomeMy Public PortalAbout5417-5429 ROSEMEAD BLVD_Sewer__ WORKERS',COMPENSATION DECLARATION 6r`f K r`� /�/f/u ► �i/' ��7 f'herebyy,,,';�rr'ffirmFthdt I have.a i(:et$Irco a of consent to self insure, oc cirrtifrii ate of Workers,,Compensation Insurance, or 76A642D a cev^f£it�lrco"y.thereof (SeG 3800, Lab C., CE BDB(REV.B/B,, APPLICATION FOR PERMITPolicy No. Company ©s tid Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. r Date 1Z-17--Applicant C—44-2 FOR APPLICANT TO FILL IN CONNECTION DATA s CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESSI:ya , STATION y DEPTH ' ' (This section need not be completed if the work involved by the MANHOLE REFERENCE PPER LOCALITY L permit is'for one hundred dollars ($lOO)Of less.) LENGTH FROM NEAREST j TYPE OF CONNECTION I certify that in the performance of the work for which this cRoss ST.. a Y. cuReP.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. OWNER �-� NO. / I t0 CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS �� 19 NOTICE TO APPLICANT: If, after making this Certificate of CITY 4 TEL.NO. AFFIDAVIT 7A�MENT 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 STWIDENING comply with such provisions or this permit shall be deemed . revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT f 3"�f I hereby affirm that I am licensed under provisions of Chapter USE OF YS 9 (commencing'with Section 7000) of Division 3 of the Busi- BUILDINGS r CHARGES ness and Professions Code, and my license is in full force and effect, yT CONTRACTOR 13 .4 CONNECTION CHARGE FEE License Numbe�rwZ� ate Lic.Class Z/ ADDRESSREIMBURSEMENT FEE Contract 0 /�/3.,,.17d'�l Date - /Z 7— Y� I -33 Q DISTRICT NO. GROUP MAP PROCE SED BY CITY - TEL.NO. / PG ❑ lam exempt under Sec. of the L.A.Co. LICENSE NO. / � CLASS �_ L. U' l� 0 Plumbing Code and/or Sec. of the NO: J DESCRIPTION OF WORK FEE V FINAL � VALIDAON HOUSE SEWER CONNECTING TO DATE _` .—�� B. & P. Code for the following reason PUBLIC SEWER ! H SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM • Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE LOW for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fee-s��sions Code): SEWER OR DISPOSAL SYSTEM - LI I,as owner of the property,or my employees with wages as I their sole compensation, will do the work and the structure i6 11 Is not intended or offered for sale (Section 7044, Business _ and Professions Code). OWNER'S Permit $ `� 7 ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE S licensed contractors 10 construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency OWNER THIS DA � 19 for the performance of the work for which this permit is OWNER OR 1 OWNERS AG.ENT�,�Gam/ issued (Sec. 3097, Civ. C.). ADDRESS Lender's Name Lender's Address I certify that I have read this applicationand 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:Zz r inspection purposes. �4 /Z —J7—Sr 4 Signature of Permetee Date SEE REVERSE FOR EXPLANATORY LANGUAGE