HomeMy Public PortalAbout4500-4502-4504-4506 TEMPLE CITY BLVD_Sewer__ WORMERS'COMPENSATION DECLARATION
I hereby affirm that I Wit, a certificate of-consent to�seH - Q
insure or a,certdlcq a of Worken'Compensation Insurance, or Q II
a certified%py thdfsof(Sac 31500 Lab C ) M'aEV l'MI APPLICATION FOR PERMIT Il
Policy No company
ED Certified - SEWAGE DISPOSAL Certified copy Is hereby furnished ,
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department . I I
Dote Applicant ' ' ' FOR APPLICANT TO FILL IN (A16**7) CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING
,COMPENSATION INSURANCE I ADDRESS C STATION DFPM
(This section need not be completed If the work involved by the i«Km, c-1 —HW Ia6tgBN¢�, U
permit Is for one,hundred dollars($100)or less) NNcrH •
h certify Ihat the performance of the work for which t NEAR STT Y TYRE� cage v L ML TO v L
permit N Issu I shall not employ any person i man r ' L v c
No
so os to bac e s yblect to the Work. CoTape ono a OWNER A i..� • co " NO XID ND
// v • DO Eu E TRVN(fERAVi NO ROAD PEMT NO
Date Appllca
NOTICE O APPLICANT If after making this Cernfic of Gr. TEL No all
Aff"Vir WAAER EASFMENr RECORD INSTR NO DATE
Exempt n you should become subject to the .n
Com sahon provisions of the Labor code you must f hwlth DEsc IR mtoN Lor rsD T,
comply with such provisions or this permit shall be deemed Nwv MST wwENtNG �a 7 y
revoked ' BLOCK TRACT WARRIETICROACIIMENT • • j s82 MDF/it pet
LICENSED CONTRACTORS DECLARATION '''O DF B1DG
I hereby affirm that I am licensed under provisions of Chapter S¢EOF LOT Now oN L
9 (commenting with Section 7000) of Division vn 3 of the Bual &ungNcs oux,ES
ness and Professions Code and my license is in full force anjl
effect ���, / CONTRACtOR tE CONr1CTION CHARGE TEF
License Numbs/77 �E1 LIc Clogs Y ,CRESS v e REIMS RSEWENT RE y
�4.«X�3• maw
Contractor DISTRICT AID GROUP AVID iROCE55ED BY O
CI1Y NO � �"' � � E./
❑ I am exempt under Sec of the L A Co L awss tl C 0 O
Plumbing Code and/or Sec of the Nct I DESCRIPTION OF WORK EEE FINAE V �'
tousE SEWER mrmealNC To DATE �dp� VALIDA N i
B & P Code for the following reason PU&K R O
TANK GE APIT M
PITS AND/OI(DIIAINFIFID H
Date FtousE SEWER Cpa[CTIEICa To BY '3 3 4 6 0 A
Slgnaturo r CONNECT ADDITIONAL BLDG OR I. # a • e • 1 0
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor s License l SEEPAGE NT DRAINFIELD
ExTN CESSPOOL DRy E-L MANHaE ' I is * 27.50
Low for the following reason (Secton 7031 5 Buisness and Pro AFTER REPAIR OR ABANDON HOUSE
fessions Code) SEWER OR DISPOSAL SYSTEM • • • 2 7 5 05
❑ 1,m owner of the property or my employees with wages as 11. 1 3=8 5
their sole compensation, will do the work and the structure
is not Intended or offered for sole (Section 7044, Business
and Professions Code) OWNER'S Permit f -
❑ 1 os owner of the property, am exclusively contracting with AUTHORIZATION TOTAL4FEElicensed contractors to construct the project (Section 7044, I HAVE AT TIL15 DAZE A CONT ve TMED CONTRACTOR rO
Business and Professions Code) CONNER THE ABOVE DESCRINo STING D &LIC SEWERCONSTRUCTION LENDING AGENCYhereby affirm that there Is a construction lending agency SIGNED THIS IV_far the performance of the work for which this permit is O'L'D OR &A VANIssued (Sec 3097, Gv C J OWNERS AGENT
Lender's Name
I
Lender s Address
I certify that I have rood this application and a shot the
above Information N correct I agree m all county
ordin"Stateh I Ing and Sewernd vathis County to enter
pons IT purposes /
Slgnaturo of Parmltta. Dots SU■!Yi FOR iXIIIIANAT04Y LANOUAM I
., l