HomeMy Public PortalAbout4436 TEMPLE CITY BLVD_Sewer__ f
WORKERS COMPENSATION DECLARATION {�
I hereby affirm that I have a certificate of consent to self 20 DD51 OM 6M u
Insure or o certificate of Workers Compensation Insurance or - 7(1s
a candled copy thereof (Sec , APPLICATION FOR PERMIT
Policy No' Companyny Lab C
❑ Cerrlfled copy is hereby furnished SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ADDREW r STATION DEPTH
(This section need not be completed If the work Involved by the LOCAl1TY MANHOLE REFERENCE I urefR
permit Is for one hundred dollars ($100)or less ) L R
I certify that In the performance of the work for which this NE�S61r TYRE OF CCINNECT ON IENGtH FROM -
permit is issued I shall not employ any person in any manner Z Y CURB v L M I i0 P L
LEGAL PC NO _
s0 OS 10 become subject to the Workers Compensation Lows DESCRIPTION LOT NO CO IMP NO XX1 N'O
DOIe Applicont BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT PQ
NOTICE TO APPLICANT ❑ after makingthis Certificate Of AaEZS • AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOON PAGE PARCEL
Exemption you should become subject to the Workers NO OF Eli
Compensation provisions of the Labor code you must forthwith S EOF LOT NOW ON LOT HWY ORSr WINNING
comply with such provisions or this permit shall be deemed USE OF
revoked I • W LDINGS t STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT t4O
I hereby affirm that I am licensed under provisions of Chapter OWNER L r 73--r-
9 (commencing with Section 7000) of Division 3 of the Busi y Iaoliness -n / L T CHAIIGEs
ness and Professions Code and mlicense Is In full force and •,
effect CITY TEL NO 11 ��E7/�<{ CONNECTIpJ CHARGE FEE
License Number LIC Class 1 RE!"URSFMENT FEE
CONTRACToa L-�
COnhactor Date —� DISiRI<T r40 GROUP MAP PROCESSED BY
ADDRESS F p IC LEE BR PG '
❑ I am exempt under Sec of the L A Co clTr 31
is
p / TEL No -p/ •D ALL d
Plumbing Code and/Or Sec of the STATE uc FINAL _
LICENSE NO CLASS DATE DATE VALIDATION Z
B 8 P Code for the following reason IRO DESCRIPTION OF WORK FEE O
HOUSE SEWER CONNECTING 10 FINAL Y7F
Date PUBLIC SEWER By CT
SEPTIC TANK SEEPAGE RT OR W
PITS AND OR DRAINREID a
Signature ► N
OWNER BUILDER DECLARATION OISE SEWER coNNE SYSTEM
TO Z
PRIVATE T ADD 71 SYSTEM
I hereby affirm that re exempt from the Contractor s License CONNECT ADDDE SEWI BLDG OR
Law for the following reason ($ecton 7031 5 Buisness and Pro WORK TO FgUSE SEWER
fOVERFLOW SEEPAGE PIT DRAINft1LD ���r
e ons EXTN CESSPOOL DRYWELL MANHIXE E~• 1 y
I as Code)owner of the property or my employees with wages as AirER REPAIR OR ABANDON HOua - rr -c
their sole compensation will do the work and the structure SEWER OR DISPOSAL SYSTEM �3t�J L[ 1
Is not Intended or offered for sale (Section 7044 Business 1 I 16115
and Professmns Code) _
r
❑ I osowner
nt the property amt h projycontractingwith OWNER'S Permit $ q 14T� - 55 �.-
licensed contractors ro construct the project (Section 7044 ` a 5r.t1
Business and Professions Code) AUTHORIZATION TOTAL FEE 3 (HECK
CONSTRUCTION LENDING AGENCY I HAVE Ai THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ® CHANGE xl]I]
1 hereby affirm that there Is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DNELUNG TO THE PUBLIC SEWER
for the Performance of the work for which this permit Is
Issued (Sec 3097 Civ C ) 51GNEDTHIS DAYof 19_ + 'I C`
OWNER OR ICL- 1 jy� Q( l4
Lender s Name OWNERS AGENT yE
Lender sAddress 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
and hereby authorize representatives of this County to enter
u O the above mentioned roperty for Inspection purposes
Igna re of Pef,,711eei Date SEE REVERSE FOR EXPLANATORY LANGUAGE
F