HomeMy Public PortalAbout6230-6236 ROSEMEAD BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION
'a ?4. ie y'dffirm iiiat I hour a certMicoleaof clonsi6nt to self
insur„:'or a certificate of Workers'CcImpensation Insurance, or 76A642D
a certified copy thereof (Sec. 3600, Lab Cs.) CE806(REV.6/8J) APPLICATION FOR PERMIT
Policy Np. Companys
❑ Certified copy is hereby furnished, r � SEWER - SEWAGE DISPOSAL
dertified copy is filed with the county (ding inspection ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
epartment.
ISI
Date �t _Applicant �l 3ItL-' FOR APPLICANT TO FILL IN - N CTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS` ( _"
BU WING - Y
COMPENSATION INSURANCE ADDRESS (.' '''� v STATION
DEPTH
This section need not be completed if the work involved b the " UPPER
( P Y LOCALITY ��1w)t,,e {_ MANHOLE REFERENCE j� - yj J ER
.permit is for one hundred dollars ($100)or less.) ,
NEAREST TYPE,OF CONNECTION LENGTH FROM
3
CURB P.l. M.L.TO P.l
1 certify that in the performance of the work for which this CROSS ST. - a�it3 v
L.
permit is issued, I shall not employ any person in any manner _
P C NO,
so as to become subject to the Workers'Compensation Laws. OWNER 1w p A MAIL {9 CO.IMP,NO. OB NO
Date Applicant ADDRESS ) ti �{ t�gl TRUNK PERMIT NO. ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after making this Certificate of CITY (, ^,'_J7 TEL.NO. e 2-,7 AFFIDAVIT WAIVER EASEMENT RECORD,INSTR NO, DATE
Exemption, you should become subject to the WorkersLEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.SIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. �'? ,l �. CONNECTION CHARGE FEE
1.4*� CONTRACTOR >
License Number f ✓ Lic.Class n'
ADDRESS V REIMBURSEMENT fEE
Contractor 's t DISTRICT NO. GROUP MAP PROCESSED BY
.,�"U r '� iiie �(, ,Date� i A' ') '7
CITY TEL.NO. n1 - ,�..� `` SK PG Z
STATE
❑ I gf1T exempt Under Sec.——of the L.A.CO. LICENSE NO. '� p} CLAS$ 4- J ) �. �°�
111 O
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL ' ` V
HOUSE SEWER CONNECTING TO 1, r., DATE VALIDATION CL
B. $ P. Code for the following reason PUBLIC SEWER Ln
SEPTIC TANK,SEEPAGE PIT OR Z
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO B
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR Poo.DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I 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 sole (Section 7044, Business
and Professions Code). OWNER'S Permit $ / 6
❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 174
licensed 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 OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT
ADDREss
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
to
n1�t bntioned property for inspection purposes.
y
,qnature of Permittee 0
�—I-r- Date SEE REVERSE FOR EXPLANATORY LANGUAGE