HomeMy Public PortalAbout6202 SULTANA AVE_Sewer__ t WOIKERS'COMPENSATION DECLARATION
I hereby.affirm that 1 have.a certificate of consent to self 92-0002 DPW 3i87
rmure oro certificate of Workers-Compensation Insurance, or �E 808
a,Fertified>Igpy4the�P�of (Sec. 3800, Lob C,)
::E BOB APPLICATION FOR PERMIT
Policy No. Ly f t� Company Ins• �s p
❑ 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 6-8-92 Applicant.Owen Bros. Plbg. FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' fADD7RESS6202
COMPENSATION INSURANCE Sultana sTArION DEPTH
This section need not be Com feted if the work involved b the UPPER
( P Y em le Cit MANHOLE REFERENCEpermit is for one hundred dollars ($100)or less.) P y OWER
REST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this SS ST Y, CURB P.L M L.TO P.I.
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 Pat MurrayCO.IMP,NO, JOB NO.
MAIL 3606 N. R10 Hondo TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of CITY Rosemead TEL.NO. 443-1579 AFFIDAVIT =EMENT 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
NO.OF BLDGS. PERMIT NO,
LICENSED CONTRACTORS DECLARATION 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 Owen Bros. Plumbing, Inc. CONNECTION CHARGE FEE
License Number 231 741 Lic.Gass C36-20-16 ADDRESS 4265 N. Baldwin Ave. REIMBURSEMENT FEE 0
Contractor Owen Bros. PlDote 6-8-92 CITY El Monte TEL.NO. 443-0078 DISTRICT NO. GROUP MAP PROCESSED BY STATE LJC
El am exempt under Sec. of the L.A.Co. LICENSE NO. 231 741 CLASS C36-20-16 �'of , Z
8K PG Z
- � _o
t—
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL W
� VALIDATION
PUBLIC SEWER
HOUSE SEWER CONNECTING TO DATE �r,�•�, ar �_ CL
B. & P. Code for the following reason SEPTIC TANK;SEEPAGE PIT OR FINAL Z
PITS AND.'OR DRAINFIELD
Date BY
HOUSE SEWER CONNECTING TO ( v
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER 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, Bulsness 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
is not intended or offered for sale (Section 7044, Business _
and Professions Code). OWNER'S Permit g s
❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE ={
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 PUBUC 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 1 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,
a d hereby authorize representatives of this County to enter
on the above-mentioned property for inspection purposes.
6-8-92
Signature of Permittee `~ Date SEE REVERSE FOR EXPLANATORY LANGUAGE