HomeMy Public PortalAbout5751-5757 ROSEMEAD BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affipye',:eof
Ihave a certificate of consent tc self '��ve,4insure, or a cto of Workers'Compensation Insurance, or �snsaz0a certified coS 38 Lab C. 92-0002 DPW 6/88Policy 4z,,1_ 3t p � °� � = ►mss 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
department.
Date -, /Applicant .'.✓ - - FOR APPLICANT TO FILLO CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' [ArDDRESS
DING %) r
COMPENSATION INSURANCE REsS �'= :'. � �'" �c��':��C--�.,�,. STATION DEPTH
(This section need not be completed if the work involved by the g UPPER
permit is for one hundred dollars ($100)or less.)
ALITY Tem _i ,MANHOLE REFERENCE LOWER
I certifythat in the performance of the work for which this REST Rosemead - Las Tunas Drive TYPE OF CONNECTION LENGTH FROM
P SS 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 become subject to the Workers'Compensation Laws. NER Champion Development CO.IMP.NO. !OB NO.
�✓-j'•/ pp �[,� - - - - . .� MAIL 200 ceangate, 12thFLoor TRUNK PERMIT NO. ROAD PERMIT NO.
Date�A Applicant
.
NOTICE TO APPLICANT: If, offer making this Certificate of clTv Long Beach TEL.No. AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NODATE
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOTNO.
comply with such provisions or this permit shall be deemed HWY.OR ST.WIDENING
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 Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect, r.+y CONTRACTOR Mike Masanovich Constr. Co. , In CONNECTION CHARGE FEE 'J�
License Number JSLic.ClasS /j�Z ADDRESS 3 Alta Street REIMBURSEMENT FEE 8
Co ntract' 9� _LC Saba to d✓ 11'/ c,TYArcadia, CA 91CC L,No, 818-447-7518 DISTRICT NO. GROUP MAP PROCESSED BY z
STATE LIC. BK PG
❑ I am exempt ander Sec. _-of the L.A:Co. LICENSE NO. CLASS e;
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL p„
X HOUSE PUBLICSER R CONNECTING TO / DATE VALIDATION cq
B. 8 P. Code for the following reason PEPTIC TANK,SEEPAGE PIT OR /
Date 7--i�
PITS AND/OR DRAINFIELD FINAL
/
'--
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 following reason (Becton 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). OWNERS Permit 2NAMED
/�j e.` ?
❑ 1, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project Section 7044,
P I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIONTRACTOR TqBusiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TC 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
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 here b au hort'ze representatives of this County to enter
upon the60v -mentioned proper{.1 for inspection purposes.
4-16-91
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE