HomeMy Public PortalAbout6156 ROSEMEAD BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 6A6dD
Plp �omn600, Lob C,) 20002aawe as
Policy
_ poAPPLICATION FOR PERMIT Tix-
Ll
❑ 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 - � Applicant " „�.�` 1` - C` FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS RC. - � e STATION DEPTH
(This section need not be completed if the work Involved by the MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY C�%��f a �1f 1� ' LOWER
1 certify that in the performance of the work for which this NEAREST ��w t TYPE OF CONNECTION LENGTH FROM
P CROSS STy CURB P L. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation laws. "? t; [ P.C.NO.
OWNER � -� - CO.IMP.NO. JOB NO.
MAIL
Date Applicant ADDRESS CLQ 9• a°4- TRUNK PERMIT NO. ROAD PERMIT NO.
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO, DATE
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL NO
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO.
comply with such provisions or this permit shall be deemed HWY.OR ST.WIDENING
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.
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- BUILD NGS e c, . q'i CHARGES
ness and Professions Code, and my license is in full force and /�� s
effect. yCONTRACTOR _.pr. ; (•..(`,°.� , �;, - CONNECTION CHARGE FEE \//���
ff, V
License Number L/` LIC.Class ADDRESS REIMBURSEMENT FEE Z
.aYl (' {C Dat@ f 1�_ C%..*' - tg DISTRICT NO. GROUP MAP PROCESSED BY d
Contractor 1. '`r�`u r +r-^ - STA P ~TEL.NO. G„t
❑ I am exempt under Sec. _of the L.A.Co. STATE {^ uC. t '? BK PG
PlumbingCode and/or Sec. of the tInCPOENSE NO. DESCRIPTION OF WORK � FEE Ass FNA c F � `ra
c' CL
HOUSE SEWER CONNECTING TO ! DATE �°` VALIDATION �.
B. & P. Code for the following reason PUBLIC SEWER `�� �y —
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAWFIELD _
j' {' Date �/' HOUSE SEWER CONNECTING TO BY _
Signature �"{ rS J•', "tet"--''�'• PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR ►
OWNER-BUILDER DECLARATION I WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
1 hereby affirm that I am exempt from the Contractor's License EXTN. CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 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 $ f7 :>•
1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
It 4�» •,� � � •� �3
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
BUSlneSS and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. -
CONSTRUCTION LENDING AGENCY
thereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19,
r the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT
ADDRESS
Lender's Name
Lenders 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 above-mentioned property for inspection purposes.
Signature of Permittee Date SEE itEVE'RSE FOR EXPLANATORY LANGUAGE
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or rsas4zD
a certified copy the o,(sec. 3800, �,b 92,°°°'DF'W°,8E APPLICATION FOR PERMIT
Policy,N 7626 1 Company 1'� fS�
(I Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL L
❑ Certified copy is tiled with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportmentr; �' r �
Date Applicant t '�yt. FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS (, j F., LV#
(This section need not be completed if the work involved by the ,� b•„ MANHOLE REFERENCE LUPPER
OWER
permit is for one hundred dollars ($100)or less.) LLTCALITY
I certifythat in the performance of the work for which this NEAREST ' TYPE OF CONNECTION LENGTH FROM
e P CROSS ST. } Y. CURB P.L. V,L.TO P.L.
permit is issued, 1 shall not employ any person in any manner
so c.to become subject to the Workers'Compensation laws. P.C.NO.
OWNER � .�_ 'ti,6 -.�''� CO.IMP,NO. JOB NO.
MAIL 'k TRUNK PERMIT NO. ROAD PERMIT NO.
Date, Applicant ADDPESs �;r .. tf
NOl'ICE TO APPLICANT: If, after makingthis Certificate of R.° AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CITY —TEL.NO.
Exemption, you should become subject to the WorkersLEGAL
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
.
LICENSED CONTRACTORS.DECLARATION NO.OF BLDGSPERMIT NO.
$,ZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi- UU�ILDyINGS � CHARGES
ness and Professions Code, and my license is in full force and
effect. 6' CONTRACTOR �CC✓`' CONNECTION CHARGE FEE
q1JLicense Number _ f � Lic.Class—
!C2 ADDRESS oe L.E.- f .` REIMBURSEMENT FEE
s,, 5. y DISTRICT NO. GROUP MAP PROCESSED BY z
Contractor :"GP'E` L "�~� Date d t "" ! CITY ti TEL.NO. "(;-f �` '1 _ BK PG o
p ILO —
[] I am exempt under Sec. _of the L.A.Co, LICENSE NO. _'° tt. CLASS
Plumbing Code and/or Sec. of the NO. DES IPTION OF WORK FEE
FINAL
P HOUSE SEWER CONNECTING TO / .T DATE x`t VALIDATION N
PUBLIC SEWER P,.e�-r` ../'
b. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR z
PITS AND/OR DRAiNFIELDFINAL
Date �1 HOUSE SEWER CONNECTING TO BY
L",
.t T }' Y`'�,V pct - PRIVATE DISPOSAL SYSTEM '
Signature 0-w f Gs i e�c CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
PITI hereby affirm that I am exempt from the Contractor's License OVEREPAGE
SPOOL,DRYW LL, MNAFNHOLE Pilo
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM -
❑ 1,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure
s not intended or offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit $
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
Icensed contractors to construct the project (Section 7044, 1 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
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit is OWNER
OWNERS AGENT
issued (Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
Lender's Address
I certify that i hove read this application and state that the
above information is correct. l 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 above-mentioned property for inspection purposes.
ignature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have o certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A6420
a certified popy hereof Sec. 3800, o C sz-0002 DPW 6/89
t f� ( a 3 APPLICATION FOR PERMIT
Policy No Company
❑ Certi ied 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 tr f °'' Applicant =1 'L14 l�. FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATECOMPENSATION INSURAPTION NCEORKERS' AADDRESS _ w IC. 'mak t C~<'„. STATION DEPTH
(Thi,section need not be completed if the work involved by the �,;,d MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100)or less,) LOCALITY LOWER
NEAREST E' TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. ?�C Y CURB P.I. M.L.TO P.L.
permit is issued, I shall not employ any person in any manner _ W.c.NO.
so cs to become subject to the Workers'Compensation Laws. OWNER E ,JYaY CO.IMP.NO. JOB NO.
MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Dote Applicant ADDRESSy F °f 4'
N0110E TO APPLICANT: If, after making this Certificate Of CITY TEL NO AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
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
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.
SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF y
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS ;r F .,'(- � ' CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR /A-:4 ! ea CONNECTION CHARGE FEE /�•,
License Number a LIC.Class- F , ADDRESS e 1. r 4 REIMBURSEMENT FEE Z
Contractor CITY N TEL.NO. Pa •�”s" C'k DISSTT'R`ICT NO, GROUP BK MAP PROCESSED BY
PG 0
ElI am exempt under Sec. —Of the L.A.Co. LICENSE NO. �t t CLCA55 � 4 ��� �J !�`¢ f'a LQ
NO. DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the FINALQ
f" HOUSE SEWER CONNECTING TO A DATE fVALIDATION Z
B. 8 P. Code for the following reason PUBLIC SEWER _.
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
,--• Date BY
HOUSE SEWER CONNECTING TO
( (, h 6 PRIVATE DISPOSAL SYSTEM _
Signature y„dp i- tk'�i% itr-" CONNECT ADDITIONAL BLDG.OR
OWNEW-BUILDER DECLARATION WORK TO HOUSE SEWER ,
DINFIELD
I hereby affirm that I am exempt from the Contractor's License E TENFLOESS SPOOL,DRYPITWELRAMANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessiOns Cade): 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 s
and Professions Code). OWNERS Permit S / no
❑ as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE / I , = s'
I.censed contractors to construct the project Section 7044, t `nom ` F "'
P 1 ( 1 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
SIGNEDTHIS DAY OF 19_
I hereby affirm that there is a construction lending agency P t . n -•
for the performance of the work for which this permit is OWNER OR
OWNERS AGENT
issL:®d (Sec. 3097, Civ. C.).
ADDRESS
Ler;ddr's Name _ •- - •--
- .
Lender's Address }
i ceotify 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
ul),n, the above-mentioned property for inspection purposes.
°ignature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE