HomeMy Public PortalAbout6515 ROSEMEAD BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION 76A642D
CE 808(2 Bo) APPLICATION FOR PERMIT
I hereby affirm that 1 have art, to Df consent tG self SEWER-SEWAGE DISPOSAL
insure or a certificate 1 e'(•s C p on Insurance r
J qb COUNTY OF LOS ANGELES BUILDING AND SAFETY
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❑ can, Is hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
BUILOINO r STATION 740 /) OQPTX
Certified opy B filed with ih c my budding mage t n ADDRESS Seec.� V
rt '/� / 7 UFPGR
LOC?I4 MANHOLE RQPLRHNCa
D Applicant imusir-
XQAq..T TYPE OP CONNECT LENGTH FROM
CE IFICATE OF EXE PTION FRO WORKERS' cRo.. aTIlZ4T CURE • L M L TOP L
COMPENSATION INSURA CEP NO
OWNER CO INP NO JOB NO
!.ISIS TL
` section need not be completed If the work involvedMwIL VOIVtd ADDRQaa TRUNK PERMIT NO ROAD PERMIT NO >.
by the perrant u for one hundred dollars ($100) or leu) A.PI.wYIT .R vII.@..HT ....SO . a
CITY TEL NO `.r` X Owr` O
1 certify that in the performance of the work for which this LEGAL L)
permit u issued, I shall not employ any person ,n any manner DESCRIPTION LOT No XVY OR ST WIDENING Cr.
so as to become subject to the Workers'Compensation Laws O
BLOCK TRACT STATE KNCROACHMENT F
Date Applicant No OF BLOO• PERMIT NO U
NOTICE TO APPLICANT If after making this Certificate of SIZE OF LOT NOW ON LOT a
Exemption you should become subject to the Workers USE DP cHw wane Z
Compensation prov,s,ons of the Labor Code you must forth eUILDINGa
with comply with such provisions or this permit shall be CONNECTION CHARGE Past
deemed revoked CONTRACTOR
LICENSED CONTRACTORS DECLARATION ADDRKSS IMBUR.CMENT RED
1 hereby affirm that 1 am licensed under provisions of Chapter urwlcr No awoU. Mw. PRo w.o eY
9 (commencing vnlh Section 7000)of Drviswn 3 of the Basi CIT L No PD
ness and Professions Code and my license is ,n full for" and Sr E u
effect uc¢naE No cLwaa P 10
NO D[aC RIPTION OF WORK PLL
/// 3 J —�� ................I.-- TO FINAL / VALIDATION
1�( nae Num r L Cines w.uc SANK w..Iwai
]/� DATE
Or Date Y�� V / 'IT.AND/OR OwA1MI1.LO r OR
-.Us. • Hae I...TD FINAL
❑ P.IVAY....I...I SYRIA.O ow BY
1 am xempt from th licensing requirements as I am a
I
d architect or a registered professional engineer ...A I r wool......
P P B owK To Ho •e ..waw Ln
act, g in my professional capacity (Section 7051 Bus ovuF.Ow.eePwa..
mes end Profess,oris Code) ..TM CESSPOOL D IeoL.
.LTA. Re Pwu Ow w XOw.
S.wa.OR DISPOSAL
LIc or Reg No Date
HOME OWNER BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors OWNER'S Permit B 5(3
License Law for the following reason (Section 7031 5, Bus, AUTHORIZATION TOTAL FEE Z ,-Q
ness and Professions Coda) .T THIS DAY. • CONTRACT T64. :20192A
R.Y. T .H...1.B.N.. con
❑ TRACTORTO COKNBCT TH.AOV.D..CRI..D
1, as owner of the property, will do the work and the TO THE PUBLIC S.w.w # . • S . 1 0
structure is not Intended or offered for sale (Section SIGNED THIS D F la I 1
7044, Business and Professions Code) ....... 1 • S 2250
N.R.AG.NT
CONSTRUCTION LkNDINb AGENCY
1 hereby affirm that there is a construction lending agency L "` • •.• 2 2 5 0
for the performance of the work for which this permit is
Issued(Sec 3097 Civ C) 7 0 2—8 1
Lender's Name
Lender s Address
I certify that 1 have read this application and slate that the
above information is correct 1 agree to comply with all County
ordinances and State laws regulating Plumbing and Sewen
and hereby authorize represent vee of County to nteI
upon the above mentioned ty f nspe tion Pur ses
7 /� SEE REVERSE FOR EXPLANATORY LANGUAGE
S,gnatura of errnittee Dat