Loading...
HomeMy Public PortalAbout6404-6414 ROSEMEAD BLVD_Sewer__ t WORKERS'COMPENSATION DECLARATION C, � I hereb.y affirm that. I have a certificate of consent to self iasurC-, or a certificate of Workers'Compensation Insur e, Or 76A642D certified co y thereof (Sec. 3800, Lab ., — E BD8IREV.B,B,, APPLICATION FOR PERMIT Policy No G pan ©s ❑ Certl le�c P hefeby-u i �J SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS Q G lJ > STATION DEPTH This section need not be completed if the work involved b the / UPPER ( p y LOCALITY .V � MANHOLE REFERENCE � LOWER permit is for one hundred dollars ($100)or less.) NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L.TO P.L. >_ permit is issued, I shall not employ any person in any manner IL so as to become subject to the Workers Compensation Laws. P.C.NO. O OWNER CO.IMP.NO. JOB NO. U 1_ MAIL J TRUNK PERMIT NO. ROAD PERMIT NO. /Date dr v� Applicant ADDRESS / rd / AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE O NOTICE TO APPLICANT: If, after making this Certificate of CITYAZA/ TEL.NO. (, O L/ Exemption, you should become subject to the Workers' LEGAL U Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING CL comply with such provisions or this permit shall be deemed 4A? revoked. BLOCK TRACT STATE ENCROACHMENT Z No.OF BLDGS. PERMIT NO. I LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT _ _ I hereby affirm that I am licensed under provisions of Chapter USE OF 3 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 @{fec" �J CONTRACTOR - CONNECTION CHARGE FEE License Number eC�" / Lic.Class XQ ADDRESS {� REIMBURSEMENT FEE Contractor a / ate �^ � 7— / DISTRICT NO. GROUP MAP PR CESSED�FJY CITY TEL.NO. A BK PG STATE - ~ LIC. �1 � /{- ,f- �� ❑ I am exempt under Sec. of the L,A.Co. ucENSE No. � CLASS /,J ///��� /N/ J,�. Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL _ HOUSE SEWER CONNECTING TO DATE , / VALIDATION B. & P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD r Date HOUSE SEWER CONNECTING TO BY G4,+ PRIVATE DISPOSAL SYSTEM ' Signature CONNECT ADDITIONAL BLDG,OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER , 5 2 2 A OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE O Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM - �� 27,50 ❑ I,as owner of the property,or my employees with wages as ' their sole compensation, will do the work and the structure u o '� C F is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit $ 16 ❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 27 S O 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 — 47-7_ �! , 1 hereby affirm that there is a construction lending agency SIGNED THIS DAY F 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 upont bbv -m oned property for inspection purposes. �" Signature of ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE