HomeMy Public PortalAbout4359 TEMPLE CITY BLVD_Sewer__ WORKERS'COMPENSATION DECLtRATICfIl 76808 i-Bol 'rt APPLICATION FOR PERMIT
I hereby affirm cert that 1 have a certificate of consent to self CE SEWER-SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or
a certipp q y t gkpf(Sec.3go0.Lab.c. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Po1k:yW comPany shit Tna.
FOR APPLICANT TO FILL IN CONNECTION DATA
13 Certified copy Is hereby furnished.
•u"N0 STATION DEPTH
.Certified copy is filed with the county building inspection woo RES\ % III le Cit. Blvd
der��{��� 1 MANHOLE RKWMRKNCC nPP w
Date.3tJ V YlpplieentQSaTen BT06.PlbQ. LocwLlrr
LOWER
EASIEST TYPE or CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' CRoso ST. Y.
CURE P.L. M.L. TO P.L.
COMPENSATION INSURANCEP.C. No.
OWNER H1XBOn & Owen Dev. CO. IMP. No. ion No.
(This section treed not be completed H the work involved NAIL
p 9843 Klingerman St-. TRUNK PERMIT NO. ROAD PERMIT NO.
by the permit is for One hundred dollar; ($100) or less.) AP.iOwvlr Wwna Kw.mn wacowo.IN•Tw.No. o• Q.
V
e ITT TEL. No.
1 certify that in the performance of the work for which this LEGAL
permit is blued. I shall not employ any person In any manner DESCRIPTION Lor No.
so as to become subject to the Workers' Compensation Iowa. HWY. OR ST. WIDENING O
SLOCK TRACT STATE ENCROACHMENT F
Date Applicant NO. OP RLDOS. PERMIT NO. (;
NOTICE TO APPLICANT: If, after making this Certificate of slzs OF LOT NOW ON LOT iL
Exemption you should become subject to the Workers' UAE ow exwwoa• h
compensation provisions of the Labor Code, you must forth. SDILDI Mos Z
with comply with such provisions or this permit shall becoxrwwerow CONNECTION CHARGE PEE
deemed revokedOWOZA
LICENSED CONTRACTORS DECLARATION AUDRKaa walMwwaEM Enr PER
1 hereby affirm that 1 am licensed under provisions of Chapter OI•.wI<r NO.I A.... r.. Pwoelylo•T
9 (commencing with Section 7000)of Division 3 of the Bust. envR, MonteTEL. NO. — � •R ro
nest and Professions Code, and my Iiceme is in full force and uciraiaE xo. CUSS s�08, � B �.
effect. —
PcL I DESCRIPTION OF WORK Pah
isst- r.aFi-9O ro
«ou.A on........CnHO To FINAL VALIDATION
931 71.1 Lie.C
License Number- •uc..... DATE
•amc TANK.•aowOI PIT on
ContractorOw _n B oa4g__Pb6/16/81 P.I.w..1ow.11A.0110.0 FINAL
House SANK"co"Na CTIRO To
❑ 1 am exempt from the licensing requirements as 1 am a .IIIY.Ta ol.ro.Al.T.TS. EY 01
CORK TO OU561'w.L•IAO.ow
licensed architect or • registered professional engineer row"To«oO.K.au /O y
acting In my professional Capacity (Section 7031, Bus- *Y..PLow...I..... ,ORA."PIELO (�
iness and Profe siom Code). NKTN..C.uroOL.CRYWKLL.MANHOLK
Al...REPAIR ON A.AwOON HOUSE
..Waw OR ouroSAL.T•TKM
Lie.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors OWNER'S Permit $1 Qo
License law for the following reason (Section 7031.5, Bmi- AUTHORIZATION TOTAL FEE
nes and Professions Code): 20051 A
NAVA AT THIS .AC w eoNTwweT WITH THE HawalN wwrao CON-
❑ TO THE P .L eo«""Cr T«K waova oK.cwuao luyuO Oweluw0
1, p Owner of the property, will do the work and the TO r«K waste•KNR w.
structure if not Intended Or Offered for pie (Section SIGNED THIS DAY 0I IS_ • • • • 10
7090, Business and Professions Code). 0=9:O. 2 a a 1 4.00
.Aoa«r
CONSTRUCTION LENDING AGENCY AOOwa..
I hereby affirm that there is a construction lending agency a • 14.005
for the performance of the work for which this permit is
Rued(Sec. 3097.Liv.C.). 042,3-81
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above Information is correct.1 epee to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
Me-ementioned property for Impaction purposes.� SEE REVERSE FOR EXPLANATORY LANGUAGE
1. t.re., 6/16/81
of PermDate Date