HomeMy Public PortalAbout5749 ROSEMEAD BLVD_Sewer__ WORKERS' COMPENSATION DECLARATION
I hereby affix t I have a certificate of consent to self
insure, or c�te of Workers'Compensation Insurance, or 76A6420
ac�.fififf�f Q y r.eof,�(SQc. 3800, Lob W-0002 DPW 6/88
Po�c Flo. �1r Compony APPLICATION FOR PERMI
❑ 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. _.
DateApplicaV&Z L �.nz� AP- T TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' [NEAREST
1NG �^ � ® sranoN DEPTH
COMPENSATION INSURANCE ESS f
(This section need not be completed if the work involved by the LITY "' f11 MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOWER
I certify that in the performance of the work for which this T. Rosemead — Las Tunas Drive TYPE OF CONNECTION LENGTH FROM
V. CURB P.L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner P.c.No
so as to become subject to the Workers'Compensation Laws. ER Champion Development CO.IMP.NO. JOB NO.
2 Oceangate, t FLoor TRUNK PERMIT NO. ROAD PERMIT NO.
Qat@ /. -,lO Applicant! G7:$..,a+,., ..yr„�e, �y�,.�,... �' ESSAFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DAZENOTICE TO APPLICANT: If, after making this Certificate of 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
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the BUST- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and ,
effect. CONTRACTOR Mike Masanovlch Constr. CO. , Inc CONNECTION CHARGE FEE
License Numberl_C-IVO Lic.Class8
ADDRESS ' 63 Alta Street REIMBURSEMENT FEE
Contr ��-e C-Date 7"✓�`Y/ CITArcadia, CA 9100�L NO, 818-447-7518 DISTRICT NO. GROUP SK MAP PG PROLES BV 0
� .�?r�- t,�'-
STATE LIC.
❑ I am exempt Under Sec. -of the L.A,Co. LICENSE NO. CLASS
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL G:
X HOUSE SEWER CONNECTING TO2® �:-�"� DATE VALIDATION
PUBLIC SEWER �
..3"
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FiNAL
Date
y �_� HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature, CONNECT ADDITIONAL BLDG.OR oil,DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRVWELL,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 as
their sole compensation, will do the work and the structure
is not intended or offered for Sale (Section 7044, Business "
and Professions Code). OWNERS Permit $
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project (Section 7044, I 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
ssued (Sec. 3097, Civ. C.). ADDRESS
Lender's Name
Lender's Address
y
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 regulqting Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the cipove-Inentioned-,property for inspection purposes.
cc '. 4-16-91
Signal e o Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
i