HomeMy Public PortalAbout5771-5801 ROSEMEAD BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION
I herebyaffi at I have a certificate of consent to self
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insure, a(a c ite of Workers'Compensation Insurance, or 76A642D L:-•: a
a cerbffie//C A?d co , reof(Sec. 3800, Lob C.) 92-0002DPW 6/B8 APPLICATION FOR PEMIT
1 1116 6 ipany_ leixel 6/4L/
❑ 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
Dote 1�(/Applicant f%� % �x �rr�--�� FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS STATION DEPTH
(This section need not be completed if the work involved by theMANHOLE REFERENCE �p UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY Temple City LOWER
I certify that in the performance of the work for which this NEARESST. Rosemead - Las Tunas Drive TYPE OF CONNECTION LENGTH FROM
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, OWNER Champion Development CO.IMP.NO. JOB NO,
MAIL 200 Ocean ate t F OOT TRUNK PERMIT NO. ROAD PERMIT NO.
Date '%d"o�-x✓1 Applicanl�ve—d�'���P-�'e�`r ADDRESS '
NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO. DATE
Exemption, city Long Beach TEL_No.
p 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 PERMIT NO.
LOT
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- BUI!DINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. _ CONTRACTOR Mike Masanovich Constr. CO. , In .CONNECTION CHARGE FEE
License Number s Lic.Class ..� �� 8
,F"�'� ADDRESS 6 3 Alta Street REIMBURSEMENT FEE
Can.4 46 K' ���e' t at9 7 /O` CITYArcadia, CA 9100r�.No 818-447-7518 DISTRICT NO. GROUP MAP PROCESSED BY 0
.� BK PG �0-
❑ I am exempt under Sec. —of the L.A.Co. LICENSE NO. CLASS ��� � 13
Plumbing Code and/or Sec._ of the NO. DESCRIPTION OF WORK FEE FINAL LL
X HOUSE
SEWER LIC SEWER CONNECTING TO g! DATE ^� VALIDATION dJJ
B. & P. Code for the following reason
ry SEPTIC TANK,SEEPAGE PIT OR FINAL
Date ( `J PITS AND/OR DRAINF IELD FI
BY
HOUSE SEWER CONNECTING TO ..
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 (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), OWNERS Permit $ t:Z�
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATIO141 TOTAL FEE eki
licensed contractors to construct the project (Section 7044, 1 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 pop -
I hereby affirm that there is a construction lending agency A SIGNED THIS DAY OF 19_
for the performance of the work for which this permit is OWNER „
OWNERS AGENT
issued (Sec. 3097, Civ. C.). ADDRESS
Lender's Name
..�3 J. . ..
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 y ` }
ordinances and State laws regulating Plumbing and Sewers , t afi i w r k:
and hereby authbrize representatives of this County to enter
upon the of+e+fnentionecl property for inspection purposes.
4-16-91 ,.
Si6h#re of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE