HomeMy Public PortalAbout6264-6276 ROSEMEAD BLVD_Sewer__ .-WORKERS'COMPENSATION DECLARATION
I h�,Vib 'affirm that I have a cestlficate of consent to •self
Ins e,pr a certificate of Workers'Compensation I,nsurance, qr 76A642D 1
a cerhfi'A�=c�py0there011 f SQC 3Boo Lab C ) CE8b8(REV 1/831 APPLICATION FODR PERMIT `J
Policy No.= ' Q�$Ipony firansameri ca• Ins. Co. SEWER - SEWAGE DISPOSAL
'
El Certified copy Is hereby furnished
❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date 3/5/85 Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING Q
COMPENSATION INSURANCE ADDRESS _ STATION "` U DEPTH //�
(This section need not be completed If the work Involved by the LocALITv
;IT
le Cit MANHOLE REFERENCE ISL. LOWER
permit Is for one hundred dollars ($100)or less )
12certify that In the performance of the work for which this ORpusST TYPE OF Co LENGTH FROM
�! Y CURB PL ML TOPL
permit Is Issued, I shall not employ any person In any manner PC No
so as to become subject to the Workers'Compensation'Laws `'
OWNER / CO IMP NO LOB NO
MAIL TRUNK PERMIT NO ROAD PERMIT NO
Dote Applicant '' ADDRESS '�
NOTICE TO APPLICANT If, after making. this Certificate of dagv AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
CITY TEL NO
Exemption, you should become subject to the Workers' LEGAL
Compensation proviiions of the Lobor'code, you must forthwith DESCRIPTION LOT NO HWY OR ST WIDENING
comply with such provisions'or this permit shall be deemed
revoked BLOCK TRACT PSTATE EN ERMIT NO OACHMENT /
LICENSED CONTRACTORS DECLARATION NO of LOT
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 CONTRACTOR Joseph CONNECTION CHARGE FEE
License Number LIC Class ADDRESS 7821 East Garvey Avenue REIMBURSEMENT FEE
Contractor Date /CITY Rosemead CA. TEL NO 818-420 280-4201 DISTRICT NO GROUP BK MAP FG PROCESSED BY V
STATE
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❑ 1 am exempt under Sec of the L A Cc LICENSE NO 130M 134935 CLASS — � {/ 0
NO DESCRIPTION OF WORK FEE �� O
Plumbing Code and/or Sec of the FINAL VALIDATION U
HOUSE SEWER CONNECTING TO DATE
PUBLIC SEWER d
B 8 P Code for,the following reason LU
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL
Dale HOUSE SEWER CONNECTING TO BY �i7 O S O 11
PRIVATE DISPOSAL SYSTEM 1 Gl 1 0
Signature CONNECT ADDITIONAL BLDG OR - # O O O,O,, 0
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD O O 2 7,Jc'O
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 O O I O 2 7,5 O U
fessions Code) SEWER OR DISPOSAL SYSTEM U n 1 ` —8,5
❑ 1,as owner of the property,or my employees with wages as 4 V
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 Per $
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 6
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEDONTRACTOR TO
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PU$C
CONSTRUCTION LENDING AGENCY `VVHII
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
OWNERS AGENT
Issued (Sec 3097, Civ C )
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 reby authorize representatives of this County to enter
up he above-mentio operty for Inspection purposes
Slgnatur o r m'ht6e Date SEE REVERSE FOR EXPLANATORY LANGUAGE