HomeMy Public PortalAbout5729 ROSEMEAD BLVD_Sewer__ ' WORKERS'COMPENSATION DECLARATION
92-0002 DPW 3/87
I,'hereby'affirm that I have a certificate of consent to self 76A642D
insure, or a certificate of Workers'Compensation Insurance, or CE Bas
a certified copy thereof (Sec. 3800, Lab C.) APPLICATION FOR PERMIT
Policy No. Company ®s
❑ 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.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS .1l �`L y;, :' STA ON DEPTH
(This section need not be completed if the work involved by theMAtJHOIE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY LOWER
I certifythat in the performance of the work for Which this NEAREST TYPE OF CONNECTION LENGTH FROM
P CROSS ST, Y. CURB RL. M.l,10 P.L.
permit is issued, I shall not employ any person in any manner P C NO.
so as to become subject to the Workers'Compensation Laws. OWNER ;.,, {,+'" •,+.`° „�,}'i,,,�„ CO.LMP,NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Dote Applicant
Applicant ) ADDRESS ) Ii.d `{
'JJ .
NOTICE TO APPLICANT: If, after making this Certificate of CITY ;� � �x �''+'�f;�.. TEL.NO. � �¢”' '�:��,`^ '- AFFIDAVIT AIVER EASEMENT RECORD.INSTR.NODATE
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
NO.OF BL DGS. PERMIT NO.
LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT
I 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 J —
effect - _ CONTRACTOR ,. CONNECTION CHARGE FEE
CL
License Number .i^ T LiC.Class ADDRESS " T � REIMBURSEMENT FEE r
�` ,�`Y .z DISTRICT NO. GROUP MAP PRpCESSED BY 0
Contractor
i am exempt under Sec Date = e iw
CITY TEL NO t i, , 4, BK PG F z
STATE LIC.
Of the L.A.CO. LICENSE NO CLASS
Plumbing Code and/or Sec._ of the NO. DESCRIPTION OF WORK FEE FINAi
HOUSE SEWER CONNECTING TO DATE ' VALIDATIOPC LLJ
T`4 PUBLIC SEWER _- _ a
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL /?z
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM.
Signature t CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION f WORK TO HOUSE SEWER ]CC�iNTRACTOR
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL.DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, BUisnesS and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
I,as owner of the property, or my employees with wages astheir sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Businessand Professions Code). OWNERS Permit $I,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 HEREIN NAMED BUslneSs and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBCONSTRUCTION LENDING AGENCY
I 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
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. 1 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-mentionedyroperty for inspection purposes.
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE