HomeMy Public PortalAbout5701-5711 ROSEMEAD BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION
I 'Nareby a that I have a certificate of consent to self ' , gym✓
insure, or a icate of Workers'Compensation Insurance, or �snsazo
P;!CIctifie�, , °� pa oo,ny ",54_� s2-�o�DPW6,a8 APPLICATION FOR PERMIT'
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depo�rt/Fent.
Date f I '�'/Applicon��a OR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' [NEAREST
UILDING' stnnoN DEPTH
COMPENSATION INSURANCE DORES _'! J>�-s'sL_d�...'
This section need not be completed if the work involved b the UPPER
( p y OCALITY '�e Cit F MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100}or less.)
Rosemead - Las Tunas DriveTYPE OF CONNECTION LENGiH FROM
I certify that in the performance of the work for which this ROSS ST. Y. CURB P.L. M.L.TO P-L.
permit is issued, I shall not employ any person in any manner P.C.NO.
so as to became subject to the
Workers'Compensation Laws. OWNER Champion Development CO.IMP.NO, JOB NO.
MAIL 200 Oceangate, 12th Floor TRUNK PERMIT NO ROAD PERMIT NO.
Date �Applica ly✓1G ADDRESS —
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY Long Beach TEL,NO.
Exemption, you should become subject to the Workers' 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
1 hereby affirm that I am licensed under provisions of Chapter USE of
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 L
effect. CONTRACTOR Mike Masanovich Constr. CO. , In .CONNECTION CHARGE FEE
12)
License Number e/_9� Lic.Class 63 Alta Street ci
ADDRESS REIMBURSEMENT FEE
Contracf�//�""�'�^t{;—e_"e*� ��/ 7'5fl BK PG 0
LICENSE NO. CLASS �DISTRICT NO. GROUP MAP PROCESSED BY 0
�,TYArcadia, CA 9100{�.No. 818-447-7518
STATE LIC. ,k
❑ i am exempt under Sec. of the L.A.Co. iV .__, L3
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL a
X HOUSEE SEWER CONNECTING TO r DATE (( VALIDATION .
B. 8 P. Code for the following reasonPUBLIC SEWER ` �' ( Z ' ---2 Z
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINHELp
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 EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the fallowing reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ARANDON HOUSE
fessions Code): SEWER OR DISPOSAL 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 sale (Section 7044, Business
and Professions Code). OWNER'S Permit $
FE
❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL E _ _� '>
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. -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit Is OWNER OR
OWNERS AGENT
issued (Sec. 3097; Civ. C,). ADDRESS_
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, f' '
and hereby authoyize reprOSentatives of this County to enter
JJjupon!the abo,47 mentioned property for inspection purposes.
�/ rl� ✓rte��.Zr 4-16-91
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE