HomeMy Public PortalAbout5821-5827 ROSEMEAD BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby ofi sat 1 have a certificate of consent to self
76A642D
insure, ora, ate of Workers'Compensation Insurance, or
APPLICATION FOR PERMIT
a certified cc _ re f JS,�� SPCO Lab C. s2-0002DPw files
Policy N iJ �/ " �drnpany
❑ 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 :! -12-fl FOR APPLICANT TO ILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS, ..` . � .°' t'f � '
(This section need not be completed if the work Involved by the MANHOLE REFERENCE UPPER
LOCALITY'. e1Tl :. .,�.•. '. LOWER
permit is for one hundred dollars ($100)or less.) TYPE OF CONNECTION
NEAREST " —Rosemead - Las Tunas Drive LENGTH FROM
I certify that in the performance of the work for which this CROSS sr. Y CURB P.I. M.L.TO P.I.
permit is issued, I shall not ensploy 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
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY Long Beach TEL.NO.
Exemption, 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 TRACTSTATE ENCROACHMENT
. .
LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOOF BLDGSPERMIT NO.
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, /��2 CONTRACTOR Mike Masanovich Constr. Co. , In CONNECTION CHARGE FEE
License Number,;;� Lic,Class /s REIMBURSEMENT FEE
y^ ADDRESS 6 Alta Street
Contract o�'✓"L-G �--1 � C G IEE -�7-T / aTYArcadia, CA 910CFfi.No 818-447-7518 BK a
DISTRICT NO. GROUP MAP PROCESSED BY 0
�e PG
El am exempt under Sec. __._,of the L.A.Co.
STATE
NO. CLASS �c7 X114
DESCRIPTION OF WORK FEE LLt
Plumbing Code and/or Sec. of the NO. FINAL a.
XHOUSE SEWER CONNECTING TO � �^�� DATE VALIDATION N
B. & P. Code for the following reason PUBLIC SEWER 14— Z
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD _
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ►
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
! hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,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 offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $ t
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION FTOTAL FEEim #
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Cade). 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
forthe 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 hereby authorize representatives of this County to enter
upon the a, ve- entioned propertTr for inspection purposes.
4-16-91
Signature df Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE