HomeMy Public PortalAbout5439 ROSEMEAD BLVD_Sewer__ WORKERS' COMPENSATION DECLARATION /
I hereby affirm that I have a certificate of consent to self 76A642D
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insure, or a certificate of Workers' Compensation Insurance, or I 6A6a
a certified copy thereof (�otc. 3800rbC,C,) ISS APPLICATION FOR PERMIT
Policy No. Company
Certified copy is hereby furnis d. SEWER - SEWAGE DISPOSAL
❑ Cert'fied copy is filed with the ounty buildi g inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
dep rim nt.
Date 3� Applica 1 FOR APPLICANT TO FILL IN CONNECTION DATA
C TIFICATE OF EXE N FR ERS' BUILDING
COMPENSATION INSURANCE ADDRESS STATION DEPTH
(This section need not be completed if the work involved by the C I� MANHOLE REFERENCE UPPER
LOCALITY
permit is for one hundred dollars ($100)or less.) LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I 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, 1 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.U CO IMP NO JOB NO
Datep- BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
O Applicant
ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
NOTICE TO APPLICANT: If, after making this Certificate of MAPBOOK PAGE PARCEL
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 WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS 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- MAILS�{-J�l I CHARGES
J
Hess and Professions Code, and m,/license is in full force and ADDRESS
effect. C // �t1 CITY C TEL.NO. CONNECTION CHARGE FEE
License Numb r 52S • Lic.Class v� REIMBURSEMENT FEE
+ CONTRACTOR
Contra CtOf Date '131 C74 +� ^ r , r DISTRICT NO GROUP BK MAP PG PROCESSED BY
ADDRES +f
Elam exf I empt under Sec. othe L.A.Co.
p CITY 1 aq TEL.NO. —)I ' DO
Plumbing Code and/or Sec. of the STATE LIC. FINAL U
LICENSE NO. CLASS G~_ �j DATE VALIDATION Z
B. 8 P. Cade for the following reason NO. DESCRIPTION OF W RK FEE O
HOUSE SEWER CONNECTING TO "
NAL V
Date PUBLIC SEWER zzx/ O BY w
SEPTIC TANK SEEPAGE PIT OR a
Signature PITS AND OR DRAINFIELD (A
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO Z
PRIVATE DISPOSAL SYSTEM
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 HOUSE SEWER Vis_
fessiOnS Code OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL.DRYWELL.MANHOLE •••
ALTER.REPAIR OR ABANDON HOUSE E"f:'`•'`• `''•
❑ I, as owner of the property, or my employees with wages as SEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure
is not intended or offered for sole (Section 7044, Business
and Professions Code),
i i f� :_I
❑ I, as owner of the property, am exclusively contracting with - -'=• Q
licensed contractors to construct the project (Section 7044, OWNERS Permit $ p�lfj fl l i_ s
Business and Professions Code). AUTHORIZATION TOTAL FEE /� / . {�` t 7.i= -1
CONSTRUCTION LENDING AGENCY HAVE AT rws DATE A CONTRACT WITH THE HEREIN NAMED ovrancroR ro
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER 1 `==
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF l�_
OWNER OR
Lender's Name OWNERS AGENT
Lender's Address ADDRESS _. i ;) _
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordino' es and State laws regulating Plumbing and Sewers,
and her by autho e esentatives of this County to enter
upon the above- ention d property for inspect/ n put oses.
Sig to of Permit Date SEE REVERSE FOR EXPLANATORY LANGUAGE
I