HomeMy Public PortalAbout6148 ROSEMEAD BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION
•I hereby affirm that 1 have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 7sA642D
a certified x!4ea�(secp. 3800,Ja C. y � 92.0002DPW6/88 APPLICATION FOR PERMIT
Policy-No om on �
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL '
® -=ertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
depart nl. .
y F
Datr "' Applicant_ j�- f �fr t` ltx FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' FNEA
NG
COMPENSATION INSURANCE SS ) TA ON DEPTH
(This section need not be completed if the work involved by the ITY "��',` '� '� MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) EAR � LOWER
certify that in the performance of the work for which this ROSSSST. TYPE OF CONNECTION LENGTH FROM
V.
permit is issued, I shall not employ any person in any manner CURB F.L. M.L.TO P.L.P.C.NO
so cA to become subject to the Workers'Compensation Laws. OWNER k4 y+ CG.IMP.NO. JOB NO"
MAIL Dat ,_ Appl lcanT ADDRESS E1 Is"ti TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after making this Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR,NO. DATE
CITY V ��. � TEL NO. r' '7
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 TRACT STATE ENCROACHMENT
NO.OF BLDGS. PERMIT NO.
LICENSED CONTRACTORS DECLARATION SIZE OF LOT 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 ,p
effect. CONTRACTOR ` � "t.� CONNECTION CHARGE FEE
License Number ��lic.Class ADDRESS - " ( (! a REIMBURSEMENT FEE
Contractor Date "�•4 E" ,ec, r. e DISTRICT NO. GROUP MAP PROCESSED BY
z
CITY t TEL.NO. G' - BK PG �0
❑ I am exempt under Set. of the L.A.Co.
STATE
NO. .. r� CLASS ® , _-
-' r
O
DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the NO. FINAL 0:
HOUSE SEWER CONNECTING TO DATE VALIDATION fn
PUBLIC SEWER f'
B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY -'t s
( ,� /A b � � PRIVATE DISPOSAL SYSTEM
Signature } - CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION
WORK TO HOUSE SEWER PON.
SEEPAGE PIT,DRAINFIELD
I hereby affirm that i am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fesSlons Code): SEWER OR DISPOSAL SYSTEM
❑ 1,as owner of the property,or my employees with wages as .7
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business 6 "
and Professions Code), OWNER'S Permit $ /'yj Doi?
❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE '
!icensed Contractors to construct the project (Section 7044, L HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO # {
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency SIGNED THIS DAY OF & IQ
for the performance of the work for which this permit is
S
AGENT {
issued ISec. 3097, Civ. C.). OWNER - �
ADDRESS
Lender's Name
Lender's Address
I eePtify 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
uponthe above-mentioned property for inspection purposes,
t,:Signature of permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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