HomeMy Public PortalAbout5759 TEMPLE CITY BLVD_Sewer__ WOKKF:xS'COivtFF NS,1rION DF:CI.ARATI()N 808 (2 80)D
CE sos APPLICATION FOR PERMIT
CE
I heteby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insure,or a certificate of Workers'Corn pensation Insurance,or
a certified zo thereof(Sec.380t7` _ �� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. I Compan��" �"Le c) —
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN CONNECTION DATA
6UlLDING .— Jl
.—^"- _ STATION '�`y DEPTH
L,-^r t erttfled l.Opy' 3.4 filed with t V/EOuntV builfjl Inspectio ADDRESS" � � � ��"� � � ' "�
5'.Ll dep'Br� E,nt. .c MANHOLE REFERENCE '
r
LOCALITY �.F"�r �,�� �r.. , e.J LOWER
i I}ate `pplicanL .sa .NEAREST TYPE OF TION LENGTH FROM
f' CERTIF'ICA'FF_ OF EXEMPTION FROM WORKERS cRass sr—�_ �Ita� v. cuR ' P,L.
M.L. TO P:L.
COMPENSATION INSURANCE: f P.C. NO.
��.
OWNER CO.CO. IMP. NO, JOEL NO.
MAIL �q
(This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO./ n1 y
I by the permit is for one hundred dollars ($100) or less.) F.FFIOAVIT WAIVER EASEM NT RF-CORD. INSTR.NO. DATE 0
CITY TEL. NO.
I certify that in the performance of the work for which this LEGAL
permit is issued. I shall not employ any person in any manner DESCRIPTION LOT NO. HWY, OR ST. WIDENING
so as to become subject to the Workers' Compensation Laws. O
EiLQCKTRACT C4 S'TA7E ENCROACHMENT pF� �yf LL
PERMIT NO.
Date Applicant NO. OF BLDGS. LU
SIZE OF LOTNOW ON LOT
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' USE O NGs CHARGES
Compensation provisions of the Labor Code,you must forth-
'With comply with such provisions or this permit shall beCONTRACTOR, J"/'d> .,� ( •_ CONNECTION CHARGE FEE
dc'e3nea revoked Ef .Ffl 6..
` �
LICENSED CONTRACIORS DI C I AFATION ADDRESS ,F' . v! F y RElM DURSEM ENT FEE
I hereby affirm that I am licensed underp T)visiU riI of Chapter �i ,/' DISTRICT NO. GROUP SK
MAP PRO ESSEO BY
�✓ 1f1. � n6- - T rc F f
9 (comrnencing with Section 7009)of Division 3 of the Rusi- CITY
ness and Professions Code, and my license is in full force and STATE LIC. t r" '
LICENSE NO. CLASS
e1;eCt. NO. DESCRIPTION OF WORK FEE
,� (� ( HOUSE SEWER CONNECTING TO FINAL VALIDATION
Lr(ease Number— s
Lic.Class PUBLIC SEWER DATE
SEPTIC TANK,SEEPAGE PIT OR
� PITS AND/OR ORAINFIELD
FINAL ,.
HOUSE SEWER CONNECTING TO BY
PRIVATE OISPOSAL SYSTEM
El I am exempt from the licensing requirements as I am a
CONNECT ADDITIONAL.BLDG.OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
...
acting in my' professional capacity (Section 7051, Bus OVERVLOW SEEPAGE PIT,GRAINFIELD Faj
ino and Professions Code). EXTN.,CESSPOOL,ORYWELL, MANHOLE
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic,or Reg.No. Date
FFOME:OWNER-BUILDER DECLAR.ATFON
I hereby affirm that I am exempt from the Contractor's OWNERT$ Permit !
License Law for the following reason (Section 7031.5, Flusi- AUTHORIZATION TOTAL FEE p
ne'is and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREI NAMED CON-
EJ
IRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING OW ELLING
I, as owner of the property, will do tfie work and the rD THE PUBLIC SEWER.
structure isnot intended or offered for sale (Section SIGNED THIS DAY OF
7044, Business and Professions Code). OWNER OR
.OWNERS AGENT.
CONSTRUCTION LENDING AGENCY ADD REBS
hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lt:nder's Name
-11der's Address
I certify that I have read this application and state that the
'Ohove information is correct.I agree to comply with all County
C-tdinances and State latus regulating Plumbing and Set,vers,
and hereby authorize representatives of this County to enter
uPo,Alffll-above m ied property for inspection purposes.
r� r' SEE REVERSE FOR EXPLANATORY LANGUAGE,
J Signature cif lermlttee Date