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Home My Public Portal About6004 ROSEMEAD BLVD_Sewer__ 76A6420 - C",- APPLICATION FOR PERMIT W'ORK,ti:RS'COMPENSATION DECLARATION CE 808 (2-80) SEWER-SEWAGE DISPOSAL I hereby affirm that I have a certificate of consent to self BUILDING AND SAFETY insure,or a certificate of Workers'Compensation insurance,or COUNTY OF LOS ANGELES a certified copy thereof(Sec. 3800,Lab.C.) CONNECTION DATA Policy No. Company FOR APPLICANT TO FILL IN Q (,� DEPTH d STATION ! - ��- «1 L1 Certified copy is hereby furnished. BuILDtNG ! pp 6 uPPE.R ADDRESS /If C- '� .i`c 7 e MANHOLE REFERENCE -� �- 13 Certified copy is filed with the county building inspection LENGTH FROM department. LOCALITY TYPE OF CON NE CTI NEAREST - Y. CURB P.L.ev°9,1 M.L. TO P.L. Date Applicant CROSS ST. (r , — - NO. P.C.CERTIFICATE OF EXEMPTION FROMWORKERS' — CO.IMP. ND. -X,r` roe No. COMPENSATION INSURANCE OWNER �fF.• ROAD PERMIT NO. �'- MAII ;• TRUNK PERMIT NO. 0 (This section need not be completed it' the Work involved ADDRESS tl y AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. GATE Q by the permit is for one hundred dollars ($100) or less.) CITY/`., w_°` TEL. NO. `d - .Y- .S'6 t Cr I certify that in the performance of the work for which Lh15 DESCRIPTION LOT NO.LIrbALL- HWY. OR ST. WIDENING permit IS tsSUed, I shall not employ any person in any manner STATE ENCROACHMENT C.1 so as to become subject to the Workers' C.ompenSatlOn Laws. BLOCK TRACT PERMIT NO. tJJ t NO. OF BLD GS• f3. �� - `t` Applicant _ __ Now oN LOT l)at0 SIZE OF LOT CHARGES NOTICE: TO APPLICANT: If, after making this C Ificate of USE OF Exemption, you should become subject to the Workers' BUILDINGS ` CONNECTION CHARGE FEE Compensation provisions of the Labor Code, you must forth- with orth- � rE:k "' >, �V ith Comply with such prOYlSlOnS r corirRweroR or this permit shall be REIMBURSEMENT FEE �`. deemed revoked. 4 { / ( (STRICT N ROU K MAP P PR SED BY OC 4 ( ADDRESS - p O, G P LICENSED CONTRACTORS DECLARATION B G ' TEL. I hereby affirm that I am licensed under provisions of Chapter 1 cirY N LIC. 9 (,commencing with Section 7000) of Division 3 of the Busi- STATE F CLASS ` rofessions Code, and my license is in full force and LICENSE NO, c -ON OF WORK VALIDATION Np, DESCRIPTION FEE Bess and PFINAL efSeCt. HOUSE SEWER CONNECTING TO DATE '"' �./,f� } • _ PUBLIC SEWER License Number Lie. SEPTIC TANK, PITSAD/OR D SREAEINPAFGIEELDPIT�OR " FINAL iiir, ��`� HSUSE SEWER CONNECTING TO BY / Iitra PRIVATE DISPOSAL SYSTEM i I am exemptg CONNECT ADDITIONAL BLDG.OR. from the licensing requi as I am a WORK TO HOUSE SEWER licensed architect t)T a registered professional engineer OVERFLOW SEEPAGE PIT,DRAT .IELD 'F acting in my professional capacity (Section 7051, Bus EXTN.,CESSPOOL,ORY WELL,MANHOLE mess and PLOfe$,ions Code). ALTER.REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM •ic.or Reg.No. Date_ HOME OWNER-BUILDER DECLARATION OWNER'S Permit s hereby affirm that I am exempt from the Contractor's AUTHORIZATION TOTAL FEE icense Law for the following reason (Section 7031.5, Busi- I HAVE AT TIS DATE A ONIRACT and Professions Code). -TRACTOR TOH HCONNECT THE ABOVE OEISCRIB EDTH THE HEXISTINGADWELL NG E TH TO PUBLIC SEWER. - 1, as owner of the property, will do the work and the �,, DAV OF 19 i structure is net intended or offered for sale (Section SIGNED THIS 7044, Business and Professions Code). OWNER OROWNERS AGENT CONSTRUCTION LENDING AGENCY ADDRESS ,hereby* affirm that there is a construction lending agency r the performance of the work for which this permit is sued(Sec. 3097,Civ.C.).. nder's nder's Address rtify that I have read this application and state that the Ve information is correct.I agree to comply with all County nances and State laws regulating Plumbing and Sewers, hereby authorize representatives of this County to enter n the above-mentioned luR rl} f r inspection purposes. SEE REVERSE FOR EXPLANATORY'LANGIJAGF. ignrlt'iiate re of Pe mitts WORKERS'COMPENSATION DECLARATION 76A6421) CE 808 (2-80) f APPLICATION FOR PERMIT 1 hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL insuie, or a Certificate Of Workers' Insurance,or a certified copy thereof(See. 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING. STATION DEPTH ❑ Certified copy is filed with tile county building inspection _ADDRESS Uo"Mr", department. X MANHOLE REFERENCE LOWER batc- Applicant LOCALITY NEARESTTYPE OF CONNECTn, LENGTH FROM CF.RTIFfCF ATE OEXEMPTION FROM WORKERS' CROSS ST. Y.of CURB P.L., M.L.ETO P.L. COMPENSATION INSURANCE OWNER ` f ` �� co. IMP. NO, P,C,NO. NO* MAIL JOB TRUNK PERMIT NO. ROAD PERMIT NO. 0- ?This section need not be completed if the work involved v� ADDRESS 12 zZ L-_ 0 b?y the permit is for one hundred dollars ($100) or less.) =W^=IRECORD. INSTR.NO.1 DATE 0 CITY/ -"acetify that in the performance of the work for which this DESCRIPTION L "emit is issued, I -,hall not employ any person in any manner D I- . TION LOT NO. p HWY. OR ST. WIDENING as to become subject to the Workers' Compensation Laws. BLOCK TRACT STATE ENCROACHMENT UJ UJ Applicant NO� OF BLDGS. PERMIT NO. M _ U) NOTICE TO APPLICANT: If, after makSIZE OF LOT NOWON LOT malting this Certificate of z LXemption, you should become subject to the Workers' USE OF CHARGES Compensation provisions of the Labor Code, you must forth- BUILDINGS With comply with such provisions or this permit &hall be "i CONTRACTOR CONNECTION CHARGE FEE deerntd revoked. 11 REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS DISTRICT NO. ..Q.F MAP PROCESSED By I hereby affirm that I ani licensed under provisions of Chapter 'Tt� UK PG 9 (commencing with Section 7000) of Division 3 of the Buri- zz!�!CITY TEL. N6. 5 LICENSE NO. CIA.. e and Professions Code, and my license is in full force and STATk LIC. 4 effect. NO. DESCRIPTION OF WORK FEE FINAL"0111 SEWER CONNECTING 11 VALIDATION T ie.Class __/ C 3�, PUBLIC SEWER Licens,�Number DATE IAI SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD Zo 41, FINAL Contractor_ '// Date .HDU SE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM I am exempt from the licensing requirements as I ant -aC_.NN-eCT ADDIT IONAL BLDG.OR licensed architect or a registered professional engineer WORK TO...S. aoing in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELO im,s and Professions Code). EXTN.,CESSPOOL,ORYWELL,MANHOLE ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL 5151C. Lic.or Reg,No. Date_ HOMEOWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNER'S Permit License Utw for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE ness end Professions Code): I I HAVr. AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING owner of the property, will do the work and the TO THE PUBLIC SEWER. stricture is not intended or offered for sale� (Section SIGNED THISDAYOF _19- 704 - , Business and Professions Code). OWNER OR - OWNERS AGENT CONSTRUCTION LENDING AGENCY A10RESS I hereby affirm that there is a construction lending agency for the -performance of the work for which this permit is issued 3097,Civ.C.). LendQr',,Name Lender's Address_ I certify that I have read this application and state that the ,r� above information is correct.I agree to comply with all County ordinances and State laws regulating Plumbing and Sewers, and uereby authorise representatives of this County to enter upon the above-menflonet yropea�y-for ins qc%iou purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE A i'lSi re of Permi tee Ta I'll bat 1�`ORKERS'COMPENSATION DECLARATION 76A�4`q 6A' " (- APPLICATION APPLICATION FOR PERMIT . CE sos tz-sol I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL insure or a certificate of Workers'Compensation Insurance,or 'fl a certified copy thereof(Sec. 3300,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company- D Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING �" ' - r sT,ATION .�"( - f J. s J DEPYH ADDRESS v� 'd ct'd' �'d",ys,i,. .. fir, Certified copy is filed with the county building inspection / UPPER department. LOCALITY 'f `� , sF MANHOLE REFERENCE - = . _date Applicant NEAREST '" — '' TYPE OF CONN E C TIO , LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS IS T. Y. CURB P P.L. M.L. 70 P.L. kk COMPENSATION INSURANCE � r vp 7 C P,1. NO. OWER ,,+ (': L'� C.O. IMP. NO. 6 G 'O. NO. r MAIL _ (This L section need not he completed if the work involved ADDRESS J r` TRUNK PERMIT NO. ROAD PERMIT NO. 0 by the permit is for one hundred dollars ($1014) or less.) ` l� Ai FIDAVIT WAIVER EASEMENT REDO RD, INSTR.NO. DATE' U \. TEL. NO. � - I cer`ify that in the performance of the work for which this L AL �,. � pert-,it is issued, I shall not employ any person in any manner DEs RIPTION LOT NO. !r HWY. OR ST. WIDENING so :is to become subject to the. Workers' .Orn pensation Laws. BLOCK TRACT STATE ENCROACHMENT W ftL]at Applicant 1 i ` � - - f NO. OF BLDGS, PERMIT NO. t ''NO'I'IC E: 'IC.I APPLICANT, If, after ma.king this Certificate of SIZE OF LOT NOW ON LOT z Exemption 1 USE OF p you SllOnld become subject t0 the Workers' BUILDINGS CHARGES Con=pensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be CONTRACTOR - •� '_ a fc coNNEcrioN CHARGE FEE deemed revoked. REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS °�.�� afT� /�'�"r/�iz Cy I hereby affirm that I am licensed under provisions of Chapter _ °< y DISTRICT NO. GROUP MAP P ROEssen,eY �. CITY Z, TEL. NO. -. «,- O BK PG 4 (commencing with Section ^,000) of Division 3 of the Busi- mess snd Professions Code, and my license is in full force and srwTE ee. LIC` LICENSE NO w'-jCLA5S s�"�"` effect, N., DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO FINAL VALIDATION License Number '� Lic.Class^--g am P:ieLIC SEWER DATE LR SEPTIC TA.NK,SELPA E' PIT OR •' ...- � PITS AND(OR DRA NF I L-0 Contractor Date_��A ~r FINAL HOUSE SEWER CONNECTING TO BY s� PRIVATE DISPOSAL'SYSTEM 1 am exempt from e licensing requirements as I am a CO ry NECT ADDITIONAL BLDG.OR licensed architect or a registered prD professional engineer WORK TO HOUSE SEWER acting in my professional capacity (Section 7051, ug- OVERFLOW SEEPAGE PIT,DRAIN 'IELD inesS and Professions Code). EXTN.,CESSPOOL,DRYWELL,MANHOLE ALTER, REPAIR OR ABANDON HOUSE. SEWER OR DISPOSAL.SYSTEM Lic,orReg.No. _ Date HOME OWNER-BUILDER DECLARATION I herebJ affirm that I am exempt from the Contractor's OWNERS Permit f License Law for the following reason (Section 7031.5, Busi• AUTHORIZATION1 TOTAL FEE ness and Professions Code). I HAVE AT THIS DATE A CONTRACT WITH THE, H,REINN. MED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ,. I, 4s owner of the property, will do tiie work and the To THE PUBLIC SEWER. structure is not intended or offered for sale (Section SIGNED THIS DA!' of 19� 704=1. Business and Professions Code). OWNER OR 04Y'N ERS AGENT CONSTRUCTION LENDING AGENCY ADDRESS_ _ I hereby affirm that there is a construction lending agency for the, performance of the work for which this permit is issued(Sec. 3047,Cit'.C.). Lender's Name---- 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 upcl,the allove-mentioned properCy for mspe•tion purposes. SEE REVERSE: FOR EXPLANATORY LANGUAGE; i `A Sx ntt}teOflQrml tee Date,.