HomeMy Public PortalAbout5809-5819 ROSEMEAD BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION r
1 hereby of hat I have a certificate of consent to self' .
insure, ora
-ate of Workers'Compensation Insurance, or 76A642D
Poli yN certified'c //tea! f o�pc3hS Lab!/ G 92-0002 DPW 6186 e I
�� APPLICATION FC R P l RMIT
❑ Certified copy is hereby furnished. �7 SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING°AMD SAFETY
department.
Date >7-3 Applican �Gol"�'t<z.wc- +� FOR APPLICANT TO FILL IN
CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS _ -s*ea® � L.r.w STATION DEPTH
(This section need not be completed if the work involved by th@MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY LO
1 certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
CROSS ST. Y. CURB P.L, IV,I.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 CO IMP.NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS 200 Oceangatp, 19th FLOor
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY T ID TEL,No.
Exemption, you should become subject to the Workers' LEl
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 BLDGS. PERMIT NO.
LICENSED CONTRACTORS DECLARATION
SIZE OF:OT 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. /�, CONTRACTORMika CONNECTION C9-IARGE FEE A
License Number �LJ3�7✓ LIC.Class ADDRESS REIMBURSEMENT FEE (4JJ
JOrs� Si•i L1ZasC i��Qate ��� S�_ �® GT'd 37AIT"-��re t DISTRICT NO. GROUP MAP PROCESSED BY
Contract V
❑ 1 am exempt under Sec. —of the L.A.Co. STAT Yy BK PG
LICENSE NO. CLASS _ (J f /
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL VALIDATION a
CURLUSE SEWER C SEWER CONNECTING TO ��, DATE q
B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR ,- a0 Z
PITS AND/OR DRAINNELD FINAL .�.
Date HOUSE SEWER CONNECTING TO BY �..
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR Poo.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
Low 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). OWNER'S Permit $
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
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
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
issued (Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
Lender's Address -
I certify that 1 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 hereby authorize representatives of this County to enter
upon the ob(ove-,nentioned property far.inspection purposes.
Signofure pf Permittee Do t-6 SEE REVERSE FOR EXPLANATORY LANGUAGE
/! S