HomeMy Public PortalAbout5675 ROSEMEAD BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
ur ar certificate of Workers' Compensation Insurance, or
76A642D
79CN, ,pythereof c. 3800, ab C.) CE808(REV 8/8I) APPLICATI N FOR PERMIT
Policy No� pan f�iV'+' ''�_ _ Cis
Certified copy is hereby furnished. SEWER - SE AGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Date,// Applicant '^� � FOR APPLICANT TO F7�IN CONNECTION DATA
C RTIFICATE OF EXEMPTION FROM WORKERS' BUILDING QEPTHCOMPENSATION INSURANCE ADDRESS sTAnoN {/' �.� i(This section need not be completed if the work involved by'the _ MANHOLE REFERENCE fir' - j�,;",�:� UPPER
permit is for one hundred dollars ($100)or less.) ocAurY2, !I cerlif that in the erformance of the work for which ibis TYPE OF CONNECTION •- _ LENGTH FROM
y p CROSS ST ✓�/ Y. CURB y�P,y.� M.L TO P.I.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. OWNER �/ +� �/r s, Co.IMP,NO. Z_37 2,
!OB NO.
MAIL .,••.� TRUNK PERMIT NO. ROAD PERMIT NO.
Dale Applicant ADDRESS r �- ._ /1
NOTICE TO APPLICANT: If, after making this Certificate of CITY �� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO DATE
Exemption, you should become subject to the Workers' ^� �`✓ TEL N �'
LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST WIDENING
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 ,;,/y'�' 3
I hereby affirm that I am licensed under provisions of Chapter USE OF s t
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. � CONTRACTOR I N� PC�� CONNECTION CHARGE FEE d
License Numb r Z _Lic.Class_ ADDRESS { N REIMBURSEMENT FEE V
Contractor , G/ �.�Date Id 117 CITY ®r1✓ TEL NO. CIS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG ! Z
El am exempt under Sec. of the L.A.Co. STATE uC. J / O
P LICENSE NO. 9 � ClASs .0/ ��
NO. DESCRIPTION OF WOK FEE ✓" lll��� W
Plumbing Code and/or Sec. of the FINAL
HOUSE SEWER CONNECTING TO DATE _�� ./ VALIDATION d
PUBLIC SEWER y�
B. & P. Code for the following reason — SEPTIC TANK,SEEPAGE PIT OR Z
PITS AND;OR DRAINFIELD FINA
Date HOUSE SEWER CONNECTING TO BY `
PRIVATE DISPOSAL SYSTEM
Signature — CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License FXTN,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, BUlsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ 1,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 sale (Section 7044, Business _5l/
and Professions Code). OWNERS Permit $ 0 ->
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed Contractors to construct the project (Section 7044, 1 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, x}�-
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency SIGNED THIS ' DAY?OF. 19 ► + C%�L
for the performance of the work for which This permit is OWNER OR
"'on!2c,� -7
f /
issued (Sec. 3097, CIV. C.). OWNNT ADD ESS 4 ✓;�
Lender's Name I
9 w
Lender's Address 0 7 ` 5/0
I certify that I have read this application and state that +he
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorizer ntatives gf this County to enter
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bove- nti grope or inspecti urposes.
Si 1 ormiite D e SEE REVERSE FOR EXPLANATORY LANGUAGE