HomeMy Public PortalAbout5721-5747 ROSEMEAD BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION '
1' hereby affir t I have a certificate of consent to self
insure, or'a c to of Workers'Compensation Insurance, or 76A6420
aPfer- dd oVW7Treof
" S�e-c 3800, Lab C.' 92-0002 DPW 6/66
APPLICATION FOR PERM
o . _Compony
❑ Certified copy is hereby furnished. SEWER SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department. y�
Date Y-17-Ll Applicants'/ly Ott ..�z=-r t-.*'1 FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING "-� _v
COMPENSATION INSURANCE ADDRESS ' . „gam_ STATION DEPTH
(This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY Temple City LOWER
NEAREST TYPE Of CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Rosemead — Las tunas Y CURB P.L. M.L.TOP I.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. P.C.NO
OWNER Champion Development CO.IMP.NO. JOB NOMAIL .
v ADDRESS 200 Oceangate, 12th Floor TRUNK PERMIT NO. ROAD PERMIT NO.
Date
Applicant
NOTICE TO APPLICANT: If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR NO DATE
CITY Lon 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.
slzE of LOT Now ON Lot
1 hereby affirm that I am licensed under provisions of Chapter us£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
effect. CONTRACTOR Mike Masanovich Constr. Co. , InCONNECTION CHARGE FEE
Licenke Number /7 Lic.Class �' REIMBURSEMENT FEE
'`}�J/�i // �+ � ADDRESS h'�.]r,a S fi Y P P fi
COntr2ef,LL,)Z,e"lL�"s✓" di@ �T�� ��� CITY Arcadia, CA 91(*64o. 818-447-7518 DISTRICT NO. GROUP MAP PROCESSED BY z
�r BK PG V
❑
lam exempt under Sec. of the L.A.Co. SCETNSE NO. 250743 CLASS A ,�'�• f> - /f.' -
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL GL
HOUSE SEWER CONNECTING TOA, DATE r VALIDATION �?
B. E P. Code for the following reason X PUBLIC SEWER i 2_
SEPTIC TANK,SEEPAGE PIT OR FI
'i�j✓”' PITS AND/OR DRAINFIELD NAL
BY
FI
Date HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.ORACONTRACTOR
,
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
Low for the following reason (Secton 7031.5, Buisness 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
and Professions Code). OWNER'S Permit
❑ 1, as 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 HEREIBusiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TCONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction leriding agency SIGNED THIS DAY OFfor the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT
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,
and hereby authorize representatives of this County to enter
upon
Jthe abov men Toned property for inspection purposes.
4
Slgna'ure of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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