HomeMy Public PortalAbout4509 TEMPLE CITY BLVD_Sewer__ M
WORKERS COMPENSATION DECLARATION i
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers Compensation Insurance, or
a certified copy thereof (Sec 3800, Lob C > B0e(REu B/BI) - APPLICATION FOR PERMIT
Policy No Company ®s
❑ Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL
XCertlfied copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
de r
Date'-Applicant FOR APPLICANT TO FILL IN- CONNECTION DATA
CERTIFICATE OF EX I F WORKE WILDING
COMPENSAT INS NCE ADDREss - STATION OEPiEI
(This section need not be comp staid If the work involved by the 7r REFERENQ LIPPE
permit is for one hundred dollars($100)or less ) LOGAIm '
I certify that in the performance of the work far which this cR055 eT r' ivFE aF CONHER� UNGTH FROAs
permit is issued I shall not employ an Y Re PL ML TOPL >
p p y y person in any manner d
so as to become subject to the Workers'Compens tion Laws OWNER '� 00 W No P c rvo O
L oe No
vAR
Dote t Applica ADDRESS / `
k`1 Nib ROAD NO
IJD IY
NOTICE TO APPLICANT If er mak 9- his Cem to of CITY No Z�j yy3� /717 uTIDAvIr WANT__W/EASTA+Ervr REcoaD INsm No DATE o
Exemption, you should 77,
m su jai to the orkers V
Compensation provisions of bor c you must forthwith DEscRIPrIaN Oi No
HWY MST WIDENING A.
comply with such provisions or this permit shall be deemed H
revoked BLOCK TRACT STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION IIF y c�h NO a eLDGS / FERAur NO '
SIZE Of LOT /E )�
I hereby affirm ON LOT
that I am licensed under provisions of Chapter �j
9 (commencing with Section 7000) of Division 3 of the Busi-
nessand Professions Code, and my license Is in full force and
STI N
effect /J CONTRACTOR /1 COMCTION CHARGE FEE
' `
ILcccannsee NNuu,Rm,�Iber 66 LIc Clan J gppUss n REwauRSEAtENr FFF
Co a Clbr C--DOte t OTY r rnr//L�] �' DISIRIR NO GROUP WP PROO:SSED BY
9 PG
90
❑
lam exempt under Sec of the L STATE LIC
A Co LICENSE NO CU �SS r
Plumbing Code and/or Sec of the No DESUIPDIXJ OF WORK RNAl
HDusE S R 0014 c Iry TO � DATE r �.. 3 VALIDATION
B B P Code for the following reasonPUBLIC sm"
PTIC TANK SEEPAGE PIT OR RNu
PITS ANOR D/ MAIWIELD
Date HOUSE SEWER CONNECTING TO BY �cJ
ATE
Signature ' CONNECT ADDITIONAL BLDG OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE sEsvER
I hereby,a%rm that I am exempt from the Contractor s License UTN a EPooi NYWE11.iHHOU
Law for the following reason (Secion 7031 5, Buisness and Pro XnR REPAIR OR ABANDON HOUSE '
fewans Code) SEWER OR DISPOSAL SYSTEM . 1
❑ I as owner of the property or my employees wlth'woges as A
their sole compensation, will do the work and the structure 2 8 1 4,4 A
is not Intended or offered for sale (Section 7044, Business Permit f r
and Professions Code) OWNER'S
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE ' - # • •�•'• 1 Q
licensed contractor to construct the project (Section 7044 HAVE AT THIS DATE A coNTRAa wrtH THE FEREiry NAME iR iO 2 • - 2750
Business and Professions Code) I OiAW L THE ABOVE OASC 04,M EKLSi1 IT DWELLING IN T1E PUBLIC SEWER
CONSTRUCTION LENDING AGENCY • - 27505
LJ.
1 hereby affirm that there is a construction lending agency SIGNED THIS DAV OF 19Poo - -
for the performance of the work for which this permit Is oOVvr'ER M T 1207-82
Issued (Sec 3097 Civ C ) -
ADOREss
Lenders Name
.q+aR> a j73o,
Lender a Address C,
I certify that I have read this application and state that the
above Information Is correct I agree to comply with all County
ordinances and State jaws regulating Plumbing and Sewer
and hereby authorize r presentatives of this County to enter
upon the bove-men ed property for Impaction purposes _
2
It 51g otur f rit Da SEE REVEIISE FOR EXPLANATORY LANGUAGE