HomeMy Public PortalAbout5803-5807 ROSEMEAD BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION yp
I hereby off at I have a certificate of consent to self
insure, or a c ote of Workers'Compensation Insurance, or
76A6420 .,'M..J. .. ...- .'
a certified cc,,, _ ,reof Pee,?800/ILb C.) 92-0002 DPW 6/88 APPLICATION FOR PER
Pal3c f V/ !� e� ',Co Pay «�: c.
El Certified copy is hereby furnished. / SEWER - SEWAGE DISPOSAL
[L-C" copy y g inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
ertified ca is filed with the count building
departure I.
Date �
7-V/ Applicant ✓ �'' <a� � z_.�- d FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS ��yr: /� s'�2 -yX._te•,e STATION DEPTH
(This section need not be completed if the work involved by thehWNHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.)
LOCALITY Temple Cit LOWER
I certify that in the performance of the work for which this CCROSSSST. Rosemead - Las Tunas Drive TYPE OF CONNECTION ML LENGTH
Y. CURB P.L. M.L.TOP.
permit is issued, 1 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 Oceangate, 12th FLoor TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate ofCITY Long Beach TEL.NO. AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO. DATE
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor code, you must forthwith LEGAL
P P Y 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 Busi- BUILDINGS 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 1413 Lic.Class 8
ry' �J ADDRESS REIMBURSEMENT FEE
Contract1;02_A '1'1 8 L_,,�- to �/!( ! DISTRICT NO. GROUP MAP PROCESSED By' Z
cITYArcadia, CA 910M.No. 818-447-7518 BK PG O
STATE LIC. _
❑ I am exempt under Sec. _of the L.A.Co. LICENSE NO, CLASS =L"rj�.
NO. DESCRIPTION OF WORK FEE W
Plumbing Code and/or Sec. of the FINAL
X HOUSEE SEWER CONNECTING TO S ^� .DATE 3_ y l VALIDATION cn
PUBLIC SEWER
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR t v Z
PITS AND/OR DRAINFIELD FINAL
Date 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 (Sectors 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 off) $
red for sale (Section 7044, Business permit
and Professions Code). OWNER'S
❑ 1,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. - -' •- ry•
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 9wWNERS AGENT OR
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. I agree to comply with all County x ,
ordinances and State laws regulating Plumbing and Sewers, � �M1lr�� '
and hereby aythorize representatives of this County to enter `•?� � ,
c
gpon t}tefaZovQ<mentioned propertyJor inspection purposes.
4-16-91
Signbture,of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE