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Home My Public Portal About5610-5618 1/2 ROSEMEAD BLVD_Sewer__ I WORKERS COMPENSATION DECLARATION Ls I hereby affirm that I hove a certificate of consent to self W 000 DPW 3/87 Ir Insure or a certificate of Workers Compensation Insurance, or 7° 42D y °o}" ��,, ,,.� as APPLICATION FOR PERMIT;ft ❑ Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL rifled copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY Datede rtment �9 Applicant FOR APPLICANT-TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' euedNG COMPENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed If the work Involved by the MANHOLE REFERENCE UPPER UL permit Is for one hundred dollars ($IOD)or less ) LOITY R f rEAR6i I certify that In the performance of the work for which this cRoss TYPE Of CTXJNKiION LENGTH FRAM ST ✓ Y CURB PL ML TOPL permit Is issued I shall not employ any person In any manner "f so as to became subject to the Workers Compensation Laws OWNER Ol.� co tw ND Poe PO Date Date-Applicant Icanl ADEWSS MAILTRUPEiMT NO ROAD PEAMR NO „NOTICE TO APPLICANT If after making this Certificate of C1TYGC/S^� ; AFFIDAVITWAVER EASEMENT IPEcoRo IMBiq No DATE Exemption you should become subject to'the Workers IEGu Compensation provisions of the Labor code, you must forthwith DESCRIPTI LOT No HWY OR 5T WIDENING ' comply with such provisions or this permit shall be deemed revoked I BLOCK TRACT STATE ENCROAOV.TEW LICENSED CONTRACTORS DECLARATION NO OF BLOGS FERMIT NO o' "">~ f " T J � 7/ 7 I hereby affirm that 1 am licensed under provisions of Chapter UZE OF LOT Now 014 Lor SE 9 (commencing with Section 7000) of Division 3 of the Bus, BIW1Z1PPGS /'L- C oLACGEs ness and Professions Code, and my license is In full force and effect CONTRAROR N CONNECTION CHARGE fH ~"..., JtL't"e Nu/mbe_. Ic Class `^ _ nDoaE55 J, ianr `, wfwuRSEMEI'ET mEM I �Date [ INSiRICT No GROUP MAP PROCEssfo By O CRY TEl r+o BK FG U El am exempt under Sec of the L A Co I�nsE No / sass �• „J LL� ! j +l W Plumbing Code and/or Sec of the NO DEKRinot4 OF WORK EEE FINAL IKK15E SEWE4 CONNECTING TO eI DATE LL > T B 8 P Code for the following rea3on Pualcs.EwnsEPnC TµKRSEEPAGE PTT OR FFfI VALIDATION ?)VXV r / nNAL Q PITS AND/ORO IWIELD NS '1 r Date BY A HOUSE SEWER CONNECTING TO Qa PRIVATE IB Y TEM ` Signature CONNECT ADDITK &131DG oR '^ OWNER-BUILDER DECLARATION WORN i0 HOUSE BEWER w I OVERFLOW SEEPAGE Pn DRAINfIEW f I hereby affirm that I am exempt from the Contractor s Lmense EXTN CEssPOOL DRYWELL MANHOLE Law for the following reason (Secton 7031 5 Buisness and Pro- ALTER REPAIR M ABANDON HOUSE fessions Code) SEWER OR DISPOSAL SYSTEM ❑ I as owner of the property,or my employees with wages as I their sale compensation, will do the work and the structure is not Intended or offered for sale (Section 7044, Business and Professions Code) OWNER'S Permit $ ICR 1 os owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEElicensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED / Business and Professions Code) CC)114 T THE ABOVE DESCRIBED ExISTING DWELLING TO THE PUBLIC SEWER 1� a T• w f 1 CONSTRUCTION LENDING AGENCY H' I herebyaffirm that there ,s a construction lending agency SIGNE-0THIS DAYff �� 1 • e,'• g 9 cY ONNER CEA /1��'ti�. .' ► , 1( 1 ! �I +for the performance of the work for which this perms is Issued (Sec 3D97 Civ C ) OWNERS AGENi7 �- t,n � ' ADDRESS 4.�h 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 uproper or inspection purposes - Signature of Perm itt" Dote �� SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS COMPENSATION DECLARATION I herebysoffirnii that I Rove a lertiGcate,of consent to self °�-00 DPW 3/87 msurq or a certificate Qf Workers'CEmpensation Ihsaronce or >eA m ° Yom° °°o}" �., ®," APPLICATION FOR PERMIT ❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL rtdied copy a filed with the county building inspection COUNTY OF LOS ANGELES TVI G AND SAf ET' Dote Applicant ` FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BunmNG sTAnoN am INSURANCE ADDRESS (This section need not be completed if the work involved by the LOCALITY MANHOLE REI UPPER permit is for one hundred dollars ($100)or less ) R I certify that In the performance of the work for which this NEARESTT t//c//}� 01 TYPE Of QCT LENGTH FRAM permit Is Issued, I shall not employ any person in any manner CROSSY CURB PL ML TOPL so as to become subject to the Workers Compensation Laws OWNER O P C NO CO IMP NO POB NO MAIL TRUNK PERM°NO ROA°PERAUT NO Date Applicant ADDRESS -NOTICE TO APPLICANT If, after making this Certificate of CITY TEL NO, AEEmAVIi WAIVEREASEMENT REcoRD INSia NO DATE Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code you must forthwith DESCRIPTxN LOT NO HWY OR$T WIDENING comply with such provision or this permit shall be deemed - revoked BLOC( TRACT STATE ENCROACHMENT / f` A LICENSED CONTRACTORS DECLARATION No, OF aLDGs PERMrt ERo �l ✓ I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT 9 (commencing with Section 7000) of Division 3 of the Bus,- eUSE UIL°FAq DINGs non and Professions Code and my license is in full force and ��✓Z `C.4_"A-e— aiARCEs effect ++77/ CCONTRACTOR ,TJ CONNECTION CHARGE FEE Ase Numbtrfi I c C103530 ADDRESS REIMBURSEMENT FEE o < Dote (/� �7 CTTy rQA7J �y DISTRICT NO GROUP MAP PROCESSED BY TEL NO ax ❑ I am exempt under Sec of the L A Co LIiE�FLo / Q$$ -3 SL 6K - Z{` I' o NO DE RIPTION OF WORK TEE H Plumbing Code and/or Sec of the FINAL U HOUSE sEwIRSEWER CONNECTING TO DATE v W B 8 P Code for the following reason I N a SEPTIC TANK SEEPAGE PIT OR N PITS AND/OR DBAINFIELD FINAL = Date HOUSE SEWER CONNECTING TO BY PRNA Signature CONNECT ADDITICNAL BLDG OR OWNER BUILDER DECLARATION WORK TO HOUSE$EMM _ I hereby affirm that I am exempt from the Contractor s License EXTTNOVE�CEESSSPSOOPOL DRPYWELLu�HHOLE Law for the following reason (Secton 7031 5, Buisness and Pro ALTER REPAIR OR ABANDON HOUSE fessions Code) SEWER OR DISK)SAL SYSTEM ❑ I as owner of the property,or my employees with wages as their sole compensation will do the work and the structure is not intended or offered for sole (Section 7044 Business 19 31.5 A and Professions Code) OWNER'S Permit $ 0 _ ❑ I,as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE d # •,e e • 1 0 licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A COMRACT WITH THE HEREIN NAMED CO RACTOR TO ( .i• 2 7,S Q Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER �- CONSTRUCTION LENDING AGENCY Lvp ' • Z�,5 O hereby affirm that there is a construction lending agency SIGNED THIS DAY OF for the performance of the work for which this permit Is OWNER OR issued (Sec 3097 Civ C ) OWNERS AGENT 06. 05-88 Lender s Name AD°�ss V Lender's Address I certify that I hove 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 upo bove-mented4d propert or inspection purposes IF Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE ' f RS COMPENSATION DELL YN that I have a certdicote at consent to self °''00pppPW31117 artifiimte of Workers Compensation Insurance, or 10A m a Ts 00,nereof (Sec 38Lab C ) �°� APPLICATION FOR PERMIT lity PoJo.� 3;FQComponyz�P/Axa• ,LITS /UC.o m- ❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL A` A ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department Date /-12 =Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EX ION FROM WORKERS BUILDINh tv COMPENSATION INSURANCE ADDRESS _-Ad uciSTATION 5—Yr 2— (This (This section need not be completed if the work involved by the TOWITY AvwtKxEREFER �jS a U t AI6F E permit is for one hundred dollars ($100)or less ) I certify that in the performance of the work for which this CROWST Y TYPE OF NRB PLPF permit is Issued I sholl not employ any person In any mannerPC ND so as to become subject to the Workers Compensation Laws O R Co IMF No JOB NO Date Applicant CESS 220 TRU11 NK PERMIT NO ROAD PERMIT FIO NOTICE TO APPLICANT If cher making this Certificate of � C&IP No AFFDAVIT WAIVER EASEMENT RECORD INSTR rq DATE Exemption you should become subject to the Workers' 1 Compensation provisions of the Labor code you must fonhwlth DESCRIPTION LOTrA HWY OR ST WIDENING comply with such provisions or this permit shall be deemed revoked DECLARATION TRACT STATE ROACHME /J I 367 LICENSED CONTRACTORS DEARATION NO of BLDGsLOT SIZE OF EDT NOW ON LOT I hereby affirm shot I am licensed under provisions of Chapter JSE OF - 9 (commencing with Section 70DO) of Division 3 of the Busi- fulml GS U+ARGES ness and Professions Code and my license Is In full force and effect CONTRACTOR G CONrhCT10N CHARGE FEE License Number--�b 29(ebc Class a �42L ADDR� REMBU MENT FEE Y Y c /,, DISTRICT NO GROUP AMP PROCESSED BY O Controcfor ZQW-66Al Date /—/2- - fl fr- CITYTEL NO kl Q O v ix w 0 ❑ I am exempt under Sec of the L A Co i�iaTRuE NO Z uM55 — 1 a o O N NO (� Plumbing Code and/or Sec of the DESCRIPTION OF WORK TEE DATE of PUBUC SEWER HOUSE SEWECONNECTING TO DATE VALIDAT N o- R 8 8 P Code for the following reason p [ m MW IC TANS SEEPAGE%i MFINAL 8 7 J 4 A %iS AND/OR DRAINFIED Date PRIVATESEVER WNARC 1N TO BY 01SPOISAL SYSTEMo a o1 Q Signoiure CONNECT ADDITIONAL&DG OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ) o • 2 7 50 hereby affirm that I am exempt from the Contractor s License SEEPAGE%T WAINFIEIDcense EXitR CESSPOOL WYWELL MANHOLE x Low for the following reason (Secton 7031 5, Buisness and Pro ALTER REPAIR DR ABANDON HOUSE is 0 0 2 7 fessians Code) SEWER OR DISPOS4 SYSTEM ❑ I as owner of the property or my employees with wages as E-R1 1 2-8 7 their sole compensation will do the work and the structure Is not intended or offered for sole (Section 7044 Business and Professions Code) OWNERS PQTRIIf $ ❑ I as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE licensed Contractors t0 construct the project (Section 7044 1 HAVE AT THIS DAR A CONTRACT WITH THE HEREIN NAMED CONTRACTOJTOO Business and Professions Code) CCT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCYI hereby affirm that there Is a construction lending agency SIGNED THISDAY OF 1 for the performance of the work for which this permit is OWNCROR Issued (Sec 3097 Civ C ) OWNERS AGENT ADDRESS Lander 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 the above mentioned property for inspection purposes nature of Permittee Date SEEREVERSE FOR EXPLANATORY LANGUAGE n11 TJ) rim /)M — .r , a dlI n/L JL.