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Home My Public Portal About5448 TEMPLE CITY BLVD_Sewer__ WORKERS COMPENSATION DECLARATION n 1 hereby affirm that I have a certificate of consent to self 200051 DPW WSB U swora cerCompensation Insurance or tlflcote of Workers Compen ; a cerle �I ed copy Thereof (Sec 3800 Lab C , APPLICATION FOR PERMIT Policy No company � ❑ Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL ❑ Cerofied copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department Dote Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS ER1ILprro COMPENSATION INSURANCE ADDRESS (,• STATION DEPTH (This section need not be completed If The work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less ) _ -1 LDDAuiv • L R NEAREST IYR OF CONNECTION LENGTH FROM certify that In the performance of the work for This CROSSST Y CURS PI ML TOPL permit Is issued I shall not employ any person In anyy ma manner LEGALP C No so as to become subject to the -Workers Compens on Laws DESCRIPTION LOT NO CO IMP INC, IOB NO ' Dote z9 AppLmm�// BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO NOTIC TO APPLICANT If offer makin this Certificate of /.AP BOOR AFHp,Bvrt wArvfR EASEMENT RECORD INBTn rq DAR Exemption c MAP BOOK PAGE PARCEL 1 p you should become subject o the Workers NO ON LOT c Compensation with on provisions of the Labor code you ll b forthwith OW SIZE OF LOT HOW ON LOT HWY COST WIDENING comply wnh such provisions or This perms shall be deemed USE OF revoked I BUILDINGS STATE ENCROACHMENI LICENSED CONTRACTORS DECLARATION n PERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER 9 (commencing with Section 7000) of Division 3 of the Bust MAIL AOORESS CHARGES ness and Professions Code and my'license Is to full force and effect UU DTY TEL NO r CONNECTION CHARGE FEE License Number Lic Class • CONTRACTOR REIMBURSEMENT FEE Contracl0 ofe DISTRICT NO, GROUP MAP PROCESSED BY ADDRESS BK PG ❑ I am exempt under Sec of the L A Co '/fJ'/'� /yam • CM "1?4. /E TEL NO • v� J �RP Plumbing Code and/or Sec of the STATE �j/ uc IINAL Eg LICENSE NO G CLASS OAIE VALIDATION B 8 P Code for The following reason W DESCRIPTION OF WORN FEE _ O HOUSE SEWERCONNECTING f0 DOIQ PUBLIC SEWER BY Br fD 'I SEPTIC TANK SEEPAGE NI OR W Signature SEPTIC AND OR DRAINFIELD G. HWSE SEWER CONNECTING TO , N OWNER BUILDER DECLARATION t PgrvATE DI sY M _ I hereby affirm that I am exempt from the Contractors License CONNECT ADDITIONAL SLOG Ci Low for the following reason (Secton 7031 5 Buisness and Pro WORK TO HOUSE SEWER !1 lessons Code) i OVERFLOW SEEPAGE PIT DRAINFIELD -- EKIN CESSPOOL OQYWTLL MANHOLE ❑ 1 as owner of The property or my employees with wages a5 4tfR REPAIq O4 4BANDOLJ HOUSE M WER OR DISPOSAL SYSTEM their sole compensation will do the work and the structure Is not Intended or offered for sole (Section 7044 Business and Professions Code) 1 ITEM] ❑ 1 as owner of the property am exclusively contracting with licensed contractors to construct the project (Section 7044 OWNER'S Permit $ D TOTAL 55 - 35 Business and Professions Code) AUTHORIZATION TOTAL FEE UECYM 55.3° CONSTRUCTION LENDING AGENCY 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEO CONTRACTOR TO ' I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER ► `�� ,i�f for the performance of the work for which this permit Is Issued (Sec 3097 Civ C ) SIGNED THIS DAY CTF 19_ Lender s Name OWNER CANTERSAGENTODOR-0001 3/29I» Lender s Address ADDRESS C7 Yh� 1 AM 9:02 I certify that I have rood this application and state that the above Information is correct')agree to comply with all County ordinances and State laws regulating Plumbing and Sewers and hereby authorize representatives of This County to enter ' u abov man sed per�yertto( Inspecty i ignalure of Permittee t Dote SEE REVERSE FOR EXPLANATORY LANGUAGE I1 WORKERS COMPENSATION DECLARATION 0057 DPW eleB I hereby affirm that I have a certificate of consent to self 1T0O DO-51 jinsurf.y,o/Pa certificate of Workers Compensation Insurance or is Io ` Pony 38W Policy6420 Led � r, APPLICATION FOR PERMIT ❑ Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL ❑ Certified copy Is flied with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY de par ment Date 'Applicant q FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTI ROM WORKERS BUILDING / COMPENSATION INSURANCE ADDRESS -7 SE4rgN oEnN (This section need no,be completed if the work Involved by the AMrvHOIF REFERENCE UPPER permit is for one hundred dollars ($100)or less I _ _ _ LOCALITY L R ' certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION IETNGIH FROM CROSS ST r CURB PL ML Toot permit Is Issued 1 shall not employ any person In any manner LEGAL PC NO so as to become subject to the Workers Compensation Laws oESCFnvrgN LOT Na Co IMF INC, JOE,NO Dote Applicant BLOCK TRACT TRUNK PERMIT No ROAD PERMIT NO NOTICE TO APPLICANT If after makingthis Certificate of ASSEs5Ofl AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE MAP BOO¢ PAGE PARCEL Exemption you should became subject to the Workers NO Or BLOGS Compensotion provisions of the Labor code you must forthwith SIZE OF LOT NOW ON LOT Hwv OR Sr WINNING comply with such provisions or this permit shall be deemed USEOF revoked BUILDINGS STATE ENCRD LICENSED CONTRACTORS DECLARATION PERM°rv0 S� I herebyaffirm that I am licensed under OWNER provisions f t Chapter 9 (commenting ions Section 7000) of ns neon 3 of the Busl CRESS 6 sU/ CHARGES ness and Professions Code and my license is In full force and effectE.�� I CIT L61" N NO CONNECTION CHARGE FEE License Number?""I"9I LIc Class ''s` CONTflACTDR A� REIMBURSEMENT FEE Contractor Date L� N� ST DISTRICT No cRoc ssED uP MAP PRoBy E ADDRESS El am exempt under Sec of the L A Co P BI, xG CITY 11$ ` TEL NO trill—Y.- 49 a2- p Plumbing Code and/or Sec ofthe STATE `�L� tic /� FINAL 8 LICENSE NO?�Q' �J AGAR CI.ASB `� DATfATION B 8 P Cade for the following reason RED DESCRIPTION OF won FEE ;^ 1rJ4.�l HOUSESEWER CONNECTING TO FINAL 1 ITEM, W PUBLIC SEWER est 1.54 _ O SEPT TANK SEEPAGE PIT OR �1 5lanalUle Q PIi54ND OR DRAINRTTOTALELD t OWNWeBUILDER DECLARATION HOUSE SEWER CONNECTING t PRIVATE DISPOSAL SYSTEM CHECK 154 I hereby affirm that I am exempt from the Contractor s License CONNECT ADDITIONAL BLDG OR CHECK Low for the following reason (Secton 7071 5 Bulsness and Pro WORK TO HOUSE SEWER CHANGE ,QI I fesslans Code) OVERFLOW SEEPAGE PIT DRAINFIEL LATIN CE55POGJ DRYWELI MANHOLE ❑ I as owner of the property or my employees with wages as AITER PAUR OR ABANDON HOUSE 41 SEwE DISP I SYSTEM then sole Intended a,soffer will do the work and the structure QI}I]Q-I ji v J/9D. Is not intended or offered for sole (Section 7014 Business and Professions Code) _ 3407 1 AM 9 x2 6 ❑ I as owner of the property am exclusively contracting with OWNER'S Permit S licensed contractors to construct the project (Section 7044 _ Business and Professions Code) AUTHORIZATION TOTAL FEE o0 CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRAI r0 , I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EKISTWG OMLUNG To THE PUBLIC SEWER for the performance of the work for which this permit Is issued (Sec 7D97 Civ C ) SIGNEDTH15 DAY OF 19_ Lender s Name OWNER OR OWTI 5 AGENT lenders Address ADDRESS r I certify that I have read this application and state that he -abovelinformation Is correct I agree to comply with all County , Mdmonces and State laws regulating Plumbing and Sewers and herby authorize representatives of this County to enter upon ve mentioned ro� farinsae�an purposes Signo .N of Permmee DOW SEE SEE REVERSE FOR EXPLANATORY LANGUAGE W6RKERS COMPENSATION DECLARATION I h4% affirm that I have a certificate of consent to self 200051 DPW BrBR •�: - -Insure or a certificate of Workers Compensation Insurance or 7BAEMPD °ce ,ITed_cain �os^,Pa B°° 1�;, APPLICATION FOR PERMIT Pol I❑I�Certified copy is hereby fun.rshed SEWER - SEWAGE DISPOSAL L�Cer°f.ed copy is fled withathe/j/oumyy building specnon COUNTY OF LOS ANGELES - BUILDING AND SAFETY de intent,S� Y./�vi�ico�• J Dore ,' 7 Applrcanr FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING COMPENSATION INSURANCE AGGRESS f sTAn OHL oErmt (This section need not be completed If the work Involved by the MANHCEE REFERENCE UPPER Is permlr, for one hundred dollars ($I00) or less ) LOCALITY L R __ _ r _ ` =1 certify that m the performance of the work for which-this TYPE Of CONNECTION -UENGTH FRQW' his GROSS ST Y CURB PI MI TOPI permit Is Issued I shall not employ any person In any manner LEGAL r�. P c tip so as t0 become subject to the Workers Compensation Laws DESCRIPTION ?' N L/ co IMP No toe NO BLOCK Date Applicant NO TRACT TRUNK PERMIT O ROAD PERMIT N ASSESSOR AFFIDAVIT WAIVER EASEMf Ni RECORD INSTR NO DATE NOTICE i0 APPLICANT If after making this Certificate of Map BOOK PAGr�3 PARCEUIII Exemption you should become subject to the Workers NO OF BLOCS Compensation provisions of he Labor code you must forthwith WE OF LOT 5711 B S' NOW ON LOT HWY oR ST WINNING comply with such provision] or this permit shall be deemed USE OF revoked BUILDINGS 1 STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION //�� PERMIT NO 1 hereby affirm that I am licensed under provisions of Chapter OWNER L!/ G 9 (commencing with Section 70DO) of Division 3 of the Bust MAIL / ness and Professions Code and my license Is in full force and AINR Ss C ��7 CHARGES effect _ CITY a •/C CI EL NO /�L•' CONNECTION CHARGE FEE License Num r �4R776� LIc Class �)//\\��{E CONTRACTOR REIMBURSEA]FNi FEE COniroctor C1`a�k Dale / DISTRICT NO GROUP MAP PROCESSED BY ADDRESS BK PG ❑ am exempt under Sec Of the l A Co n p 7{ a CITY TEL NO VC J Q Plumbing Code and/or Sec of the STATE UC LANAI U LICENSE NO CUSS DATE VALIDATION z B 8 P Code for The following reason NO DESCRIPTION OF WORK FEE l0 U HOUSE SEWER CONNECTING TO FINAL 1 (- Dote PUBLIC SEWER BY A((T•A W SEPTIC TANK SEEPAGE PIT OR T RTS AND OR DRAINFQ1D 'Xa� Signature . 'p OWNER BUILDER DECLARATION HOUSE SEWER SON Y11E- To :rd03 }gy p PRIVATE T l Y TEM ITEMS I hereby affirm than j re exempt from the Buisntor s license CONNECT ADDITIONAL BLDG OR 1 ITEMS Low for the following reason (Secton 7031 5 Bursness and Pro WORK TO SEE15E SEWER _ fe]]IOn]Code) EXTN CES SEEPAGE PIT DPAINFFUD TOTAL .57 - 20 ERiN CESSPOOL IXtYWEII MANHOLE ❑ I as owner of the property or my employees with wages as t ALTER REPAIR CR ABANDON HOUSE n D e7.hl} OC rV�U' their sole compensation well do the work and the structure SEWER OR DISPOSAL SYSTEM Is not Intended or offered for sale (Section 7044 Business and Profession]Code) ❑ I as owner contractors the property om t the pro ly contracting wish OWNER'S Permit S a �QQ—��1 771.779 licensed ofes to construct the project (Section 7044 Business and Professions Code) AUTHORIZATION TOTAL FEE D 1 }b 1 AM 8:26CONSTRUCTION LENDING AGENCY ; I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR To , 1 hereby affirm that there Is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING To THE PUBLIC SEWER for the performance of the work for which this permit is - .. Issued (Sec 3097 Cv C ) SIGNED THIS DAY OF j9_ OWNER OR Lender s Name OWNERS AGENT Lender s Address 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 Th above me one operty for inspection purposes Signature of Perm lRee Date SEE REVERSE FOR EXPLANATORY LANGUAGE