HomeMy Public PortalAbout6022 ROSEMEAD BLVD_Sewer__ , WQRKERS' COMPENSATION DECLARATION C�
I #terepy iffirm that I have a certificate of consent to self 20-0051 DPW 6189 u
Ihsvre, or a cer
tificate of Workers' Compensation Insurance, or 76A642D
PolicrylfNo�Ap ?�he6e Compon8 $ � r -_ w ? APPLICATION FOR PERMIT
O Certified copy is hereby furnishSEWER - SEWAGE DISPOSAL
Ceoified copy is filed with the"runtybuilding in @ Scn COUNTY OF LOS ANGELES BUILDING AND SAFETY
d��ar�ment." ,ry
Dote_.,_ &fApplicant a"` i
'' FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGi - J
s
COMPENSATION INSURANCE ADDRESS ) A,�q STATION DEPTH
S
(This 5eCi10n need not be completed the,y.'Ork involved by ihP. LOCALITY ��� if ��, UPP
MANHOLE REFERENCE � >:ac ?, C1 � � MOWER
permit is for one hundred dollars ($100) or less.)
t CO 'jION
! certify that in the p@rfperformancec f the work for which this NEAREST TYPE OF LENGTH FROMCROSS ST. v CURB P L ML TO P L
permit is issued, I shall not employ+'any person in any manner
LEGAL P NO
SO a5 10 become subject t0 the Workers' Compensation Laws. DESCRIPTION LOT NO. ,-:_j .MP NO TOB NO
Date Applicant BLOCK TRACT TRUJ TRUNK PERMIT NROAD PERMIT NO
NOTICE TO APPLICANT: If, after makin this Certificate Of ASSESSOR AFFIDAWT WAIVER EASEMENT RECORD INSTR NO DATE
g MAP ROOK PAGE PARCEL
Exemption, you should become subject to the Workers'
NO.OP BLDGS,
Compensation provisions of the Labor code, you must forthwith SIZE OF:LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. -BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATIONPERMIT No
I hereby affirm that I am licensed under provisions of Chapter o'stNER tJ
kJ
9 (commencing with Section 7000) of Division 3 of the Busl- MAIL
ADDRESS CHARGES
mess and Professio s Code, and myr license is in full force and
effect. -ry. f - CONNECTION CHARGE FEE.
< ^"� CITY TEL NCD.
-a� a
License Number Lic.Closs _ .�• �" RE:MBURSEMFNr FEE
CONTRACTOR e;a. �_
Contractor U 4. .'". �'•�' Date f E `�t a�... � .4 .._. he �.- $- 0:5?RIOT NO GROUP MAP PROCESSED BY
.. ADDRESS •" �.A BK PG y�
❑ I am exempt under Sec. of the L.A.Co. ) 7?. /!� F "� .'
CITY �.t.., .. f af'�:: TEL NO. %'�� �:...'� ,� c.r
Plumbing Code and'or Sec. of the STATE LIC. FINAL
LICENSE NO CLASS DATE VALIDATION
B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE /� f d
Jjj) OUSE SEWER CONNECTING TC FINAL C,
Date- ouBuc SEWER ( By
SEPTIC TANK SEEPAGE PI.JR LU
SlgnOfUl@ _ PTS AND R DRAINFIELD 4.
HOUSE SEWER CONNECTING TO N
OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM ` ?
I hereby affirm that I am exempt from the Contractor's License 7NNECT ADD T ONAL BLDG OR
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK To HOUSE SFWER ltu
OVERFLOW EEPAG€PIT DRAINEIELD A�.�,,,C
feS5ian5 Code): EXTN CESSPOOL DRYWEtI MANHOLE �y . v
-:❑ I,as owner Of the property, or my employees with wage$as Al TER. REPA R OR ABANDON HOUSE
SEWER ORI SPOSAL SYSTEM
their sole compensation, will do the work and the structure
is not intended or offered for sole (Section 7044, Business
T
and Professions Code).
1, as owner of the property, orn exclusively Contracting with permit $ TO A# 233 . 65
licensed contractors to construct the project (Section 7044, OWNER'S
Business and Professions Code') AUTHORIZATION TOTAL FEE C.
C CK
CONSTRUCTION LENDING AGENCY HAUS AT THIS DATE a CONTRACT WITH THE HERE N NAMED '_QNTRAl TOR TO T» � �3 f( ,
I hereby affirm that there is a construction lending agency
CONNECT THE ABODE TIE;RIBEo Fxlst,N,DWELt ,'O THF PUBL,r SEWER
for the performance of the work for which This permit is
issued (Sec. 3097, Civ. C 1 SIGNED THIS_, _DAY OF i9 _0I 1i#I
wNER LIR E.1000—'f.�_ �,a:
Lender's Name --.—, -. --._._-�- OWNERS AGENT yf ,r; �• f�.r
ADDRESS i dT--.it t � �( ;�'+'FEI.t� k t! �:E. .+,�.°.°i .L AM it]:
Lender's Ad . ss
I certify IIIt I have read this applycaoon and state that the
above infr anon is correct I1$ofing
a ee to comply with all County
ordinances Ind State taws Plumbing and Sewers,
and her by authorize reprtives of this County to enter
uponthein ave-mentionedrty for inspection purposes.
Sign u e of Permittee & `=rJ.+ate SEE REVERSE FOR EXPLANATORY LANGUAGE
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