HomeMy Public PortalAbout5535 ROSEMEAD BLVD_Sewer__ L WORKERS COMPENSATION DECLARATION 204MI DPW 6139
I hereby affirm that I hove o certificate of consent to self
inswe or a certificate of Workers Compensation Insurance or 7BA642D
a certifiedF�r.o�pa� C MC
copy thereof (Sea 3 Lob C ) A APPLICATION FOR PERMIT
Policy NR[LXy(LCompon >F1eS_�,
❑ Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL
❑ Certified copy is Bled with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment
DotEB 3I'gS Appl'conr 'i- t�pL•y` Jailp � FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BtntdN
COMPENSATION INSURANCE MORE N' STATION DEPTH
(This section need not be completed if the work involved by the T�� MANHOLE REFERENCE UPPER
Permit is for one hundred dollars ($100)or less ) LOCMITY .eEs I
I certify that in the performance of the work for which this NEAREST Q AxbW rvRE OF CC CURB CN UINGTOPR,
cRaes ST . cuae PL int TOFL
permit is issued I shall not employ any person In any manner LEGAL PC NO
So as to become subject to the Workers Compensation Laws DESCPoPbON LOT NO CO We NO )OB No
Date Appllccn, BLOCK TRACT TRUNK FERru1 ND ROM KOMI NO
NOTICE TO APPLICANT If after making this Certificate al AAT#�N AFFIDAVIT WAIVT4 EASEMENT RECORD INSTR NO DATE
Exemption you should become subject to the Workers NZ�As NOOPAGE FARDEL
Compensation provisions of the Labor code you must forthwith SUrE OF LOT NO
io S
Hwv OR$t WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked BUILDINGS STATE ENCROACHWN1
LICENSED CONTRACTORS DECLARATION RERAUT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER ZFK-
9 (commencing with Seaton 7000) of Division 3 of the BUST MAIL
ness and Professions Code and my,license is in full force and a1 CHARGES
effect p GTY TEL �� 2- CONNECTION CHARGE FEE
L icense Number4YDLy-s�I-s�tic Classy RDMBu NT FF
y�bdN-J Ah:%Dote 8-31-'�.a CONTRACTOR
COntIaCrO DISTRICT NO GROUpr MAP PROCESSED BY
ADORESS T� p BSC PG
011 am exempt under Sec of the L A Co G _qO DO 'TEL NO � a
8
Plumbing Code and/or Sec of the STATE a HATE VALIDATION OZ
LICENSE No Z�� L%w DAR
B 8 P Code for the following reason Nor OESCRUITDN 01,WORK FEE
HCAISE SEWER CONNECTING TO FINAL f
Date PUBLIC SEWER BySWIC W
RiT$AND TANK
04 DaANNELID AGE PIT� a
Signature ,
OWNER BUILDER DECLARATION HOUSE SEWERwfa CONNEaNG 10
Z
PRIVATE DiSPOSAE Sv TEM
I hereby affirm that I am exempt from the Contractors License CONNECT ADWTTONAS CDG OR 10
Law for the following reason (Secton 7071 5 Buisness and Pro WORK TO HOUSE SEWER
fessions Code) ovf RFLOW SEEPAGE COT DRAINFIELD a
(KIN CESS
PV'OL DRVWEII XAANHQE IIIc
El as owner of the property or my employees with wages as ALTER REPAIR OR ABANDON HOUSE 73.50
thou sole compensation well do the work and the structure
SEWER Of DISPOSAL SYSTEM
Is not Intended or offered for sole (Section 7044 Business 1 ITEMS
and Professions Code) /�7�Eb
❑ I as owner of the property am exclusively contracting with Tfy
Ap773.77
licensed contractors to construct the project (Section 70" OWNER'S Permit f p lFEM
Business and Professions Code) AUTHORIZATION TOTAL FEE K3, y,Es�s�� EsEE
CONSTRUCTION LENDING AGENCY T HAVE AT THIS DAR A CONTRACT WITH tilt HEREIN NAMED ON1aAC'Go, , Mwiff .00
I hereby affirm that there is a construction lending agency CONNCT tHE ABOVE DESCRIBED EXISTING DWELLING,TO THE PUBLIC SEWER
for the performance of the work for which this permit, Is
issued (Sec 3097 Civ C I SIGNED THIS DAY OF % 19 �yy (E(� p/}
Lender s Nome OWNER OR {pp�tAA.11 V/J1�95
OWNERS AGf[{1, _ —
Lender s Address .Dost$$,,,II�i.7� ffn.E'1 -3/tstd 04 2135 1 PM 4:15
1 certify that I hove read this application and state that the
above Information Is correct I agree To comply with all County
ordinonces and State jaws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon the above mentioned roperty far inspection purposes
_
Ignature of ermiltee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE