HomeMy Public PortalAbout5707 ROSEMEAD BLVD_Sewer__ WORKERS' COMPENSATION DECLARATION
I her,:by affirm that I have a cert;firnte of consent to self 2U-D05t DPW E 8y u
S-Ofe, or'a certificate of Workers' Compensation Insurance. or 76n642D
a-1`��c' d copy th . (ser 3800 Z � , sAPPLICATION
SE�`INI aA SEWAGE DIISPOSAL
• "Palley o Trpany
4-111 Certifiers copy is hereby furnished
ri?lcertifled copy is filed with th 4ntv build_ing ir. pection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deart ent •+
Cate � Applicont ' i®—�_""' FOR APPLICA -Z TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' SU 1-DING
DEPTH_
COMPENSATION INSURANCE ADD
UPPER
(T}:IS 5$rPIOn need not be fam pleled.f the work involved by the LOCALITY /�•'!d- --" �✓ _ >� C M3?!VHO;E REFER€NCE LOWER
permit is for one hundred dollars 11001 or less.i ! TYPE OF rOrdNECTION
I certifythat in the performance of the work for which this NEAREST €rdGrH FROM
p• CROSS ST. y CURB P L M L To R
permit is issued, I shall net employ any person Ir, any mar Her LEGAL. P c, NO
so as to become subject to the Workers Compensation Laws. DESI-RIPT O'N t_01 NO.
C) IMP NG i06 No
Date Appircant BLOCK TRACT TRUPdK PERMIT NO ROADPERMIT NO
NOTICE TO APPLICANT: If, after r)ak,n his Certifi ASb£SoOA AFFIDAviT wAIvER EASEMENT RECORD INSTR NO DATE
rate. rf MAP SOCK PAGE PAHc`;EL
Exemption, you should become subject to the Workers'
No cP at.E)Gs
Compensation provisions of the Labor code, you must ferthwi+h SIZE OF 10T NOW ON LOT
::+:WY OR ST WIDE N.ra.G
comply with such provisions or this permit shall be deemed USE OF
revoked. 8011 DINGS SATE ENCROACHMENT
LICENSED CONTRACTORS DEC''ARATION veRMlr Nr,;
f hereby affirm that i am licensed under provisions of Chapter OWNER, 3 •,.
4 (commencing with Section 7000) of D;vision 3 of the Susi- ;AIL CHARGES
oDRE
Hess and Professions Cade, and m�Ilrense is in full force and O
effect. CnY �! :.. .i'I_.NO. L>NN'ECT(INCHAR+.3F,FEE
License Number lie.Class " vF MauRSEMENr E€e
Z _ - CON FHACTOF
;� �, F .'.- ! '1" [STRICT NO ,POJP MAV CES5ED BY
Contract.. _ { c PRp
r - ADDRES.; :° "�„? �L e._>C.,! i.f-- BK PG
I am exempt under e., of the 1.A.Co. Cr [.� f ;-
IFIL NO O
Plumbing Code and for Sec of the STATEue FINAL U
LlcEras rx> - G! :LAs,;
DATE VALIDATION Z
B. & P Code for the following reasonNO. DESCRIPTION OF WORK FEE A 0
HOUSE S•EVlzR C:ONNE 1'4C.Tc) �yyp--
.. GUfe VIJB IC.SEW.k t! -- B-+' - */]o� LU
AFP _TANK EEPAC- c T OR ,per �
P AND R RAINFIEI D
5lgnature _--- — -- N
OWNER-BUILDER DECLARATION He Js€SEWER SY ter 1;TO
PR vP.E 0 P SSolAL S`r EM Z
I hereby affirm that I om exempt from the Contractor's License CONNECT A,)DI,IONAL B.Deb OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOOSE,EWER
RflC1W EEPAt,£PT ORAINfiFLD
fessions Cade): EXT.: CFSSPJOE.DRYWEL. MANHOLE
L� 1, as owner of the property,or my employees with wages as A TER REPAIR OR ABANDON-CUE
ENli$OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure
is not intended or offered for sale (Secticn 7044, Business „,,....
and Professions Code), -- '
1, as owner of the property, Orn exclusive{y C>niracting with -
licensed contractors to construct the project (Section 7044, OWNER'S Permit $ t '
Business and Professions Code) AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY HAVE AT H:_; DATE A cc,r TRACT WITH THf -EkFIIJ NAME N >Ae'nR rr,
hereby affirm that ?here is a construc41on lending agency '^^F- THE,a8 eE DE SCR 5 3 EKISTfr
for the performance of the work for vvh,Ch this permit .s J1 7,11
issued (Sec. 3047, Civ. C} SIGNED THIS_ DAY or___--_.-----_?p—
CTNNEP O3 ..,..
Lender's Name CIVINEPS AGENT
Lender's Address--- ----__--_----.._---. Aai,ufss
I certify that I have read this appI,coticn and state that the
above information is correct. I agree to comply with all County
ordinances and State lavv4 regulating Plumbing and Sewers,
and hereby authorize representatives of this Cet.v,ty to enter
upon t et r ve m rrlionl property for inspection purposes.
Ignature of Perm tree Da?e SEE REVERSE FOR EXPLANATORY LANGUAGE