HomeMy Public PortalAbout6030 ROSEMEAD BLVD_Sewer__ ' WC?RKERS' COMPENSATION DECLARATION
g 2
hweLy .n#firm that have a certificate of consent to self t r
fS-(TQ61 pPU'V 6(S9
insure, or a certificate of Workers' Compensation Insurance or,
r J` 76Af'4`D
n certified cp jhergof (Sec 380Qrtab� 7.
- APPLICATION
TI®N OR PERMIT
Policy No
# �J Certified copy is hereby furnished.
SEWER - SEWAGE DISPOSAL
[j Certified copy is filed with tIJ�- unty bolding,lr spection COUNTY OF LOS ANGELES BUILDING AND SAFETY
departmenttJ i,
Date t,(JApr hcont y �` � FOR APPLICANT TO FILL IN CONNECTION DATA
t �
CERTIFICATE Of EXEMPTIOt FOM WORMERS' pu.tplNV r
COMPENSATION INS6RANCE AnDRE s AnoN DEvnq
' -�' .
(This section need not completed 14 the work involved by the LOCALIT -14 1$ f, r �( nAnt otE REe•eeNCE -, j °'ER
permit is for one hundred dollors,($'100)or less,) OwER
NEAREST TYPE OF CO TiGN LENGTH FROM
I certify that in the performance of the work for which this cpossS upH 4 Pt V TOPL
permit is issued, I shall not employ any person in any manner LeGAI P Np
so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO CC, IMF No JOB No
I BLOCK TRACT TRUNK.PERMIT NO ROAD PERMIT NO
Date--Applicant�_—
NOTICE TO APPLICANT If, after making his Certificate of ASSESSOR AFFIDAVr WAVER €EMENT RECO110 IN-1111 NO DATE.
g MAP BOOK PAGE PARCEL.
Exemption, you should become subject Ia the WorkersNO.OF BLUES _
Compensation provisions of the Labor code, you must forthwilh S0-OF LOT NOW rN LOI r ORS, WIDENING
comply with such provisions or this perr-nit shall be deemed USE OF
revoked BUILDINGS [ATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION �yP€RMIT NO
OWNER f ,:
I hereby offirm that I am licensed under provisions of Chapter Y
9 (commencing with Section 7000) of Division 3 of the Busi- MDC)AE .>AIL CHARGES
ness and Professions Code, and mV license is in full force and T'
effect. (0NNEcriON CHARGE FEE
j
License Number �f 2 Lic Class c vaBURSEMENT FEE
'ZiAA
w 1 CON WAC7rJR At- �,lk, 6-J ) k �`'�
Contractor 1 ` Date ° r (f'" ,, STRCT NO GROUP MAP PROCESSED BY
fi ADOFi w 8K PO.
J I am exempt under Set. of the L A. Co. 41.C)
CITY TEL,NO. 4
Plumbing Code and%or Secof the STATE i.IC. ,;NAL U
LICENSE NO CLASS DATE , .Y - VALIDATION Z
B. {f, P. Code for the following reason NO. DESCRIPTION OF WORK
FELE . O
HOUSE$EWE COvNE N'TO �'vAt
v_--Cate UBLIc SEWR xPU
SEPTIC TANK SEEPAGE P T OR W
Signature PTS AND OR DRA,NFI .D
OUSE SEWER c NNECT NG To
OWNER-BUILDER DECLARATION PRIVATE DISPOSAL SYSTEM _ z
I hereby affirm that I am exempt from the Contractor's License �-CNNECTADD TIONAL BI DG OR
Lave for the following reason (Section 703).5, Buisness and Pro WORK To HOUSE SEWER �,qE
fessions.Code)+ DVERFi;7wEEPAGE PIT DRAINFIELD
txTIN CESSPOOL DRVWEIL MANHO5 E
� '�`t
L_J I,asowner of the property, or my employees with wages as Ad ER REPAIR OR ABANDON-OUSESEWER OR DSPOSAt SYSTEM. "
their sole compensation, will do the work and the structure ° 3"t ' ♦
s O: i.
is not intended or offered for sole (Section 7044, Business :`
and Professions Code) r
4.
I,as owner of the property, am exclusively Contracting with r-- t
licensed Contractors to construct the project (Section '7044, OWNER'S Permit $ � �%6 M. 233 - 65
Business and Professions Code). AUTHORIZATION TOTAL FEE z s i y ,,
CONSTRUCTION LENDING, AGENCY HAVE AT THIS A'F. A CONTRACTniTH T JF T'(PE NT'(PE N NAMED CONTRAC70,R To t_
hereby affirm that ?here is a construction lending agency Cc,NNECT HE A&),E DESER BE €x ST;N(,PW[uiNG TO THE PuBL.0$€wER R_. -5E
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.). , 7. SIGNED THIS D.Ar OF 19�
OWNER 01. p
Lender's Namev.NN€
��----_-- — _ R Ar,ENr _
ADDRESS �I m
Lender'sp Address yC'� _ 6�E 3 t A Llnl w
I certifyf thot I :have read this application and state that the
above i` ormation is Correct t agree to comply with 0!1 County
ordmanc-s and State laws p qulating Plumbing and Sewers
and he;,4by authorize repro�set)tanves of this County to enter
upon thk?jabove mentioned, p061ry for inspection. purposes:
SEE REVERSE FOR E%PIANATORY LANGUAGE
g elture o of Permittee Date