HomeMy Public PortalAbout5450 TEMPLE CITY BLVD_Sewer__ WORKERS COMPENSATION DECLARATION zo4o5T DPw eNBB
I here4y affirm that I have a cenlflca(e of consent to self r 20-Ml
in Ore or&certificate of Workers Compensation Insurance or -
o certified copy thereof (Sec ny Lab C ) _ APPLICATION FOR PERMIT
Policy No.i�l0sss Company oavroT nn R -.1,.-
❑ Certified copy Is hereby furnished I E' �, I SEWER - SEWAGE DISPOSAL
Q'C'ertified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment
Date 619/196 Applicant FOR APPLICANT TO FILL IN _ CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS euILdND SO 'm]pjg CITY mow. STATION _ DEPTH I F
COMPENSATION INSURANCE ADOgEss -
(This section need not be completed if the work involved by the • LOCALITYE (IT]' CAMANHOLE REFERENCE OGPER
permit Is for one hundred dollars ($100)or less ) I
I certify that In the performance of the work for which this NEAREST - rvN OE CONNECTgN IENGIH FROM
GROW ST v CURB P L M I rapt
perms Is issued I shall not employ any person m any manner LEGAL PC NO
so as to become subject to the Workers Compensation Laws DESCRIPTION IAT NO CO IM➢ NO - NOB NO
Date Applicant BLOCK -TFACT IRUNR PERAUI NO ROAD PFRMJI NO M `
i NOTICE TO APPLICANT f after Makin This Certificate of I ASSESSOR AFFIDAVIT wArvER EAMMINT RECORD INSTR NO DATE
Exemption c f.NP BOOK PAGE PAPCEL
p you should become subject' the Workers NO OF BLDGS -
Compensation provisions of the Labor code you must forthwith WE OF LOT Navy ON LOT NwY QRST wWFNtNG
comply with such provisions or this permit shall be deemed USE OF
revoked T BUILDINGS STATE ENCROACHMENT
I • LICENSED CONTRACTORS DECLARATION PERMIT NO
I hereby affirm that 1 am licensed under provisions of Chapter
DINNERBLANIM DONSTRUMON
9 (com menu ngc with Section 70DO) of Division 3 of the Busl MAIL W. EC2NRIA AVENUE
ADDRESS CHARGES
sass and Professions Code and millicense Is In full force and pp �' �.e�e
effect , CITY M�AJIA' CPN 910141L N918/574-0&38 - CCNNECTION CHARGE FEE
License Number T97AA4 Lc Class - C/36 C116 _ _
F. �41R[XI`IE & S(t1S INC. CONTRACTOR FRAW MARRONE & S(NS IN(.. RDMBURSEMEM fFF
Contractor Cate 19/1144; n�upc�.�. GSTRIO NO GROUP MAP PROCESSED BY
ADDRESS 701NJ ILkIER AZUSA ROAD y ex PG
❑ I am exempt under Sec of the L A Co ,{•�p 3 >>
G TEL N v• 3.%
Plumbing Code and/or Sec of the BUTS UC FINAL U
LICENSE No 397$84 CLAss C/36 C/16 DATE VAUIS
B 8 P Code for the following reason No DE'scwPTION OF roan FEE - p
Date P&TSE SEAR CONNECTING TO ^^ FI (_
SEVIER /1 U
SEPTIC TANK SEEPAGERITOR AE -73- 54
�NyE
Signature PITS AND OR DRAINFIELD . TOTAL 73- SRS
OWNER BUILDER DECLARATION .OUSE SEWT[c CONNECTING TO
, LZL
PRIVATE DITSPO15AI SYSTEM
I hereby affirm that I am exempt from the Contractors License CONNECT ADINTIONAL BLDG OR rL�B•/�t�
Law for the following reason (Section 7031 5 Bu,sness and Pro wORX TO HOUSE SEMI? `L'RTCLdS
fesslons Code) OVERFLOW SEEPAGE PIT DRAINFIEID KEC ]3.50
r EXTN CESSPOOL ORYwELL MANHOLE
❑ I as owner of the property or my employees with wages as ALTER REPAIR GN ABANDON HOUSE wR' .00
is
compensation well do the work and the structure SEWER OR DISPOSAL SYSTEM
Is not intended ar offered for sole (Section 7044 Business Ir
and Professions Code)
• • P
❑ I as owner of the property am exclusively contracting with OWNER'S P@nmlf S _ FN�EvtFFL
licensed contractors to construct the project (Section 7044 27 WW'VlF�1FF'sIFFss
Wi 1/ 2/96
Business and Professions Code) AUTHORIZATION TOTAL FEE 173 1"
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO '
I hereby affirm that there Is a construction lending agency ' CONNECT THE ABOVE DESCRIBED EXISTING D UUIrNI TO THE PUBi SEWER pt,t
for the performance of the work for which Ihis permit Is C 4#- LE/E p4 < 4047 1 PM 4:33
Issued Sac 3097 Civ C ) SIGNED THIS 4 DAY QN'41.� 1 l T
W ITER OR
Lender s Nome OWNERS
Lender s Address ADDRESS -
r
I certify that I have rood this application and state that the
above Information Is correct I agree to comply with oil County - A.
ordinances and State laws regulating Plumbing and Sewers
and hereby authorize representonves of this County to enter '
upon the abo mentioned property for Inspection purposes
Signature of Permittee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE