HomeMy Public PortalAbout5505 ROSEMEAD BLVD_Sewer__ WORKERS COMPENSATION DECLARATION MOOSE DPW SMI hereby affirm that 1 have o certiftcole of consent to self �&p
Insure or a certificate of Workers Compensation Insurance or
Policy fir` h";°` po380.0,W;IQ APPLICATION FOR PERMIT
❑ Certified copy .s hereby fwn.shed SEWER - SEWAGE DISPOSAL
❑ Certified copy Is fried with the county budding Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment
Date _Apphcon,T Q Ca E.)CMIL)E_TlFOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE ApORESS lIAIIOEI OE/TH
(This section need not be completed If the work involved by the Lam , MANHa[ttFNPEIvcE i M%R
permit is for one hundred dollars(2100)or less ) IINGTH FROM
I certify that m the performance of the work for which this NCADISSei TYPE OF CONNECTION
permit is issued I shall not employ any person m any manner NL.l1 r Cuae r L M L lar L
so as to become subject to the Workers Compensation Lows LEaAI P c `iso
1 P OESCRI AL LOT NO CO IMO NO tee NO
Date Appllconl MOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT If otter making This Certificate of ASSESSOR AFFIDAVIT w.IVII EASEMENT INCOME) INSTR NO DATE
Exemption 9 DAM BOOT( PAGE PARCEL
p you should become subject o the Workers NOOFM10GS
Compensation provisions Of the labor code you must forthwith SIZE OF LOT NOW ON LOT HWr COST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked BUILDINGS STATE ENCIO4CHM(NT
LICENSED CONTRACTORS DECLARATION PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of The Bus. WIL
mess and Professions Code and my license Is In full force and AOIDKSS CHARGES
effecTCITy TEL NO CONCHARGE FE
CONNECTION E
License Number JqOLL¢ Class PEIMBURSNAENT FEE
r L� 1 CONTRACTOR UL
Contractor T I ��l DISTRICT NO GROVP MAr raOCESYE)ey
ADDRESS 24L, LA)2 O BA PG y
❑ 1 am exempt under Sec of the L A Co pit, IiATEL NO
Plumbing Code and/or Sec of the !TATE sec
LICENSE No kfl'�(� aAss FINAL
DATE VALIDATION
B 6 P Code for the following reason No oEacTRmnoN OFM K FEE Z�—Q rp
SEWER TO FINAL
Dote HSE Yer
U
SINK TANK SEEPAGE RI OR W
Signature PIS AND OR DRAINFIELD a
OWNER BUILDER DECLARATION p Spwta CONNECNNG TO ► _
I hereby affirm That I am exempt from the Contractor s LicenseCCANECT ApplllOrwl ELLOG OR SvS10
Law for the following reason (Secton 7031 S Bulsness and Pro WORK TO HOUSE SEWER
fearons Code) OVERT SEEPAGE AT OIAINFIEID
WL
(KIN CESSNORYwEU MACCT.`.
ANHDL[ ACC
❑ 1 as owner of the property or my employees with wages as AIT(R REPAIR OR ABANDON Hour ��I 7
0
thou sole compensation will do The work and the structure SEWER OR O.SPOSAI SYSTEM 3'307 69.3
Is not Intended or offered for sole (Section 7044 Business 1 ITEMS
and Professions Code)
❑ I as owner of the property am exclusively contracting with TOTAL 69.30
licensed controctors to construct the project (Section 7044 OWNER'S 1 15Permit t CACK 69.30
Business and Professions Code) AUTHORIZATION I TOTAL FEE 7' C .�f
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HER(w NAMED C° RACTOM TO ,
I hereby affirm that there IS O construction lending agency CONWCT THE ABOVE DESCRIBED I}ISIING OWNING TO THE FUBtK SEWER
for the performance of the work for w this perms is
Issued(Sec 3097 C..v/v���C ) SIGNED THIS DAY OF 19_
Lender s Name \P IL N(R
pwS AG(rvT 0000-0001 4/13/93
9192 1 AM10:+0
Lender s Address ASN/..4sU T ADDRESS
1 certify that I hove read this oppllcotion and state that the
above mformation is correct I agree to comply with oil County
wdrnonces and State lows regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
u the abo a mens ne progeny for msp non purposes
Signa T
re Of Erin lupe D le I SEE REVERSE fOlt EXPLANATORY LANGUAGE