HomeMy Public PortalAbout5349 TEMPLE CITY BLVD_Sewer__ • WORKfRS'COMPENSATION DECLARATION -
1 hereV,affirm that I have a cemhcate of consent to self
insurp or a cerRficote of Workers'Compensation Insurance,or 14A4xRD
°P ilo4Ccmpa ;tQ- � ®,�°'�" °'°" APPLICATION FOR PERMIT
❑ Cerhfied copy is hereby furnished SEWER - SEWAGE DISPOSAL
2T.Hified copy is filed with the county buddln inspa I COUNTY OF LOS ANGELES BUILDING AND SAFETY
depanm nt /
oa(�` plc tY —� FOR APPLICANT TO FILL IN CONNECTION DATA
CERT�F EXEMPTION FROM WORK S' eLIEOINc
COMPENSATION INSURANCE ADDRE-ss tN
(This section need not be completed if the work involved by the LorALnY hVU`1HOLE RErd"N"E r
permit is for one hundred dollars ($100)or less )
I certify that in the performance of the work for which this NAREsr nPE OF M L TN FROM `
rma is issued I shall not employ an Cao55 sT r Re v L M E TOPI.
Pe P Y Y person In any manner PC No
so as tobecome subject to the Workers Compensation Laws C4 IMP FIo JOB NO
MAIL NK PERMIT NiO ROAD PERMIT NO
Dole-ApplicantRFss
NOTICE TO APPLICANT If after making this Certificate of �. TEL
^ AFFIDAVITWA VER EASFMEN RFODRD W5 R NO DATE
Exemption you should become subject to the Workers'
Compensation provisions of the Labor code, you must forthwith DFscR Pri qN tai No Hwv oR si WIDENING
comply with such provisions or this permit shall be deemed
revoked Btoac TRACT STATE ENCItIDAC
arS 1 � /
LICENSED CONTRACTORS DECLARATION slnoF for loOF
FN S PATNO ,o
I hereby affirm that I am licensed under provisions of Chapter / 0 I
9 (commenting with'Section 7000) of Division 3 of the BmUSE OFi BUII.oNGS CHARGES
nets and Professions Code and my license is In full force and
effect tpNTRAa CONNEC 10N oIARc>f FEE Y
License n r Lic Close � ADDSRSEMENT FEE O
LAI / Date/D 3 —102 � IMMICt NO P MAP SSE°BY u
❑ lam
a/pt und( of the LA Co SENO uC h� / 1_ FG 0
Plumbing Code and/or Sec of the No DESCRIPTION K Ig NNAL /,J h.•
HOUSE SEWER CONNECTING r0 DATESEWE ` VALIDIAI IQ 0 A ENV
B d P Code for the following reason PUBLIC R
SEPTIC TAN( SEEPAGE ATM HN
PITS AND/OR MAINHEW
Date- HOUSE SEWER CdJNECTING i0 BY
(.`�. PRNATE SYS a le
Signatur "�� ODNNI ECT ADDITIC BERG M / 2 7.5 0
OWNERA ILDER DECIARAYION WMX TO HOUSE SEWER ►, • • •23'18 Z•] 5 7 O
OVERFLOW PAGE AT DRAINFIEW
WE
I hereby affirm Phot I am exempt from the Contractor s License EM CESSFDRYwEU. EAATTTIOtE
Law for the following reason (Secton 7031 5, Buisness and Pro- ALTER REPAIR OR ABANDON HOUSE 0
fessions Code) sEWER oR DTSPoSAt ssT
❑ I as owner of the property,or my employees with wages asl
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044 Business permit f
and Professions Code) OWNER'S
❑ 1,as owner of the property am exclusively controcting with AUTHORIZATION TOTAL FEE is U
licensed contractors to construct the prolect (Section 7044, I HAVE AT NIS DATE A CONTRACT WITH THE HEREIN NAMED COI RACTOR TO
Business and Professions Code) CONNECT 111E ABOVE DESCRIBED EXISTING DWELLING r0 THE PUBLIC SEWER
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there Is a construction lending agency SIGNED THIS DAY OF 19_
for the performonce of the work for which this permit is OWNER Oa
317
Issued (Sec 7, Civ C ) OWNERS AGENT
Lender s Name IN ADDRESS
Lender's Address
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 laws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon the above-mentioned property for insp coon urposes
Signature of Permit Dry T_ 5!E REVERSE FOR EXPLANATORY LANGUAGE '