HomeMy Public PortalAbout5819 ROSEMEAD BLVD_Sewer__ WORKERS' CC,;MPENSATION DECLARATION
hereby �o firrh that I have a certificate of consent to self 20-W51 DPW 6t89 y.: x,r �{ F ,,p ,xi 6'`£_�, 4
imsu'e, or a certificate of Workers' Compensation Insurance, or
76A642D
a sic ,fie o ereof ,Sec 38 , � .,_ APPLICATION FOR PERMIT
Policy Na 1 CCmpr,n,,,_.= "--- SEWER - SEWAGE DISPOSAL
❑ Certified copy is hereby furnished.
[] Certified copy Is filed with the ccyynty building in ectian �, COUNTY OF LOS ANGELES BUILDING AND SAFETY
Dated rtn,e t. .✓� .i
?`Applieanr_ �� _J _ _ y' L FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDREss STA'ION DEP ti
(This section need not be completed If She work involved by the •„�: �a'�a -- - MArvr+%EREEERErdCE OPPER
LOWER
permit is for one hundred dollars ($100) or less.I LOCALITY *- _r`'. `:" t Z
NEAREST TYPE Oc CONNECTION LENGTH FROM
1 certify that in the performance of the work for which this C FOSS S1 Y Y CUPS r i M r TO P E
permit is issued, i shall not employ any person in any manner LECA- P( NO
I'
Sa as to became subject to the Workers'Compensation taws. DESCRIPTION LOT NO. CO )AAP NCL jos NO
BLOCK 7RP.CT TRUNK PERMI?NO ROAD PERMIT N01Dater ___Applicant___
ASSESSOR AFFIDAVIT WAP ORD 1NSTR NCl DATE
NOTICE TO APPLICANT: If, after making this Certificate of MAPBOOKPACE PAtRC,EL
Exemotion, you should become subject, to the Workers' No of EsLOGS
Compensation provisions of the Labor code, you .must forthwith SIZF OF LOr NOW [,Or
p p Y Hwr GR ET wIDeNING
comply With such provisions or this permit shall be deemed user:
revoked. BUILSTATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIr No
I hereby cffirm that I am licensed under provisions of Chapter crWPiLH C k ;� qL
4 (commencing with Section 7000) of Division 3 of the Busi- MAIL r.HARG€s
ness and Professions Code, and my license is in full force and ADDRESS
effect. Ct Y TEL NO, CONNECT ON CHARGE EEE
License Numbef ! -.-TLic Class_ REIMBURSEMENT FEE
® GONTRACTO t 4-9 0) ro 71,�
Contractor ��t Date i �y yy�� DISTRICT NO GROUP MAP PROCESSED BY
/ ADDRESS 2-' --=Z *�" 8K PG
I am exempt under Sec, of the L.A,Co.
C1 11 TEL,NO. <1 v 0
Plumbing Code and'or Sec. of the STATE -- LIC. P NA
LICENSE:No. t - ALI" CLASS DATE- !!, '> VALIDATION z
B. K P. Code for the following reason_ NO. DESCRIPTION OF WORK FEE >i O
HOUSE SEWER CC?NNEC`ING TC FINA[ U
,Date P B SEWER - BY i � W
SEPTI'TANK SEEPAGE PIT OR
$ignatUre _ _. -PiT.S AND CCR DRAT NFIf LL �
1Ut)-E SEWER NNE T NG TO
OWNER-BUILDER DECLARATION PR ArE Pc 5AL SYSTLV ® Z
I hereby affirm that I am exempt from the Contractor's License cc r ELT ADnI CJNAE BIDE OR , ,_,, �; ,_„`,57
Law for the following reason (Secton 7031-5, Buisness and Pro &0"TO HOUSE ;E�%FR -
OVERFtOw SEEPAGE PIT DRAINFIEIO
fessians Code.) ExTN CESSPOOL DRYWEIL.MANHO'.E
1 I, as owner of the property, or my employees with wages as ALTER REPAIR OP ABANDON HOUSE �.
S tifr"ER i)R D SPOSAL SYSTEM _
their sole compensation, will do the work and the structure _07AL 66 ..,,ol.,,'
is not Intended or offered for sale (Section 7044, Business t
and Professions Code). — t F',
u I, as owner at the propertyr am excl_jsively contracting with
licensed contractors to construct the prosect (Section 744.4, OWNER'S Permit $
Business and Professions Code): AUTHORIZATION FTOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT ?NLS DATE A CONTRACT W TH THE HFRPN NA,MEC CONTRA TOR Ti;
I hereby affirm that there i5. a construction lending agency i-lON ---T THE ABGvt DESCRIBED IxIST ING g1NEU Nu TO THE PUBLIC SE`.NFR
for the performance of the work for which this permit Is ® i X6^•i
issued (Sec 3047, Civ. C.). SpC,fvED THIS-DAY 7F 17
:JV✓NER OR.
Lender's Name,-- ----------T--- 'TWNERS AGENT _
ADDRESS_ .._
Lender's Address- - -
I certify that I have read this applicat!on and state that the IIIIIIIIIIIIIN
above informatinn is Correct. 1 agree to comply with oil County
ordinances nd State laws regulating Plumbing and Sewers,
and here authorize represent i ea rof this County to enter
upon e ave-mentioned r for inspe tion Purposes,
gnature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE