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Home My Public Portal About5928-5934 TEMPLE CITY BLVD_Sewer__ WORKERS' COMPENSATION DECLARATION y� 20-0051 DPW 6189 I hereby affirm that I have a certificate of consent to self u ir�re, or cS certificate of Workers'Compensation Insurance, or 76A642D a certified i a y/thereof (Sec. 3800, Lo C.) , . APPLICATION FOR PERMIT Policy Norte 4,f -Company ❑ Certified copy is hereby furnished - SEWER - SEWAGE DISPOSAL (� Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department- _ .., .. Dote Applicant ;j OR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM'WORKERS' BUILDING DEPTH r COMPENSATION INSURANCE ADURESPr jk' '�' Q, (Thissection need not be completed if the work involved by the e-.+' „/ r' MAN'-IDLE REFERENCE UPPER permit is for one hundred dollars($100)or less.) LocAUTY r _ d LowER certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM CROSS sr. � .f' '�.� `� Y CURB pL ML TOPL permit is issued, shall not employ any person in any manner LEGAL P C NO so as to become subject to the Workers' Compensation Laws. —R DESCRIPTION LOT NO. CO 'IMP NO JOB NO 1r r( y a_ C �pp ✓ .� BLOCK TRACT TRU'.r,PERMIT NO ROAD PERMIT NO licont NOTICE TO APPLICANT' If, O ter makingthis CertlfiCOte Of ASSESSOR A;RDAVI? WAIVER EASEMENT RECORD INSTR NO DATE. MAP BOOK PAGE PARCEL Exemption, you should become subject to the Workers' NO.OF BLDGS.. Compensation prov,sions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST w,DENING comply with such provisions or this permit shall be deemed USE OF51 revoked. BUILDINGS f - " STATE ENCROACHMENT ' LICENSED CONTRACTORS DECLARATION ,' . oovNeR - }`/ ' PERM.T f+iC I hereby affirm that I am licensed under provisions of Chapter _��` 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL ness and Professions Code, and my license is in full force and ADDRESS %` p ✓ �/ ,: c�ARGEs effect. „� � CITY �� TEL,NO L. CONVECTION CHARGE FEE License Numbec/, Lic. Class ( � « �} j REM8.IRSEMENT FEE CUNTRAC UR J'� DIS'alri NO GROUP MAP PROCESSED By COntracto i #3 �ST or ate i t �J` w J f ADORES 4.'”` ssr^– ,Y BR PG I am exempt under Sec. of the L.A. Co. �; �� `��j "ms-s CITY "TEL.NO. I �f� a. Plumbing Code and/or Sec. of the s nTE p. uG. �a+-§ FINAL LICENSE N _ CLAS: i � ,,,;,. DATE 7 VA NIDATION B 8 P. Code for the following reason NO. QEQRIPTION Of WORK_ FEE r J 1 0 qp HOUSE SEWER gNNE:N.G._T:D FINA'- � W Date 1 ?UESL!C 5bq `7 `� BY SEPTIC TANK SEEPAGE P.i OR LU Signatur@ PITS AND OR DRA'NF ELG rip OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING To � Z PRIVATE DISPOSAL SYSTEM I hereby affirm that I om exempt from the Contractor's License 7NNECT ADDITIONAL BLDG OR Law for the following reason (5ecton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER fessions Code)' OVERFLOW SEEPAGE PIT DRAINF,ELD EXTN CESSPOOL.tDRYWEU MANHOLE I, as owner of the property, or my employees with wage as ALTER. REPAIR UR ABANDON HOUSE - - SEWER 0R 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), v 0 1, as owner of the property, am exclusively contracting with OWNERS Permit $ � t} licensed contractors to construct the project (Section 7044, •-- _- Business and Professions Code). AUTHORIZATION TOTAL FEE .^J CONSTRUCTION LENDING AGENCY ; HAVE AT THIS DATE A CONTRACT AITH THE HEREIN NAMED _ONTRAc:10R TO � - � ••• I hereby affirm that there Is a construction lending agency CONNECT THE AFCvE DESCR,BED ExIST_NG DWELLING TO THE PL EL(SEWER , for the performance of the work for which this permit is issued (Sec. 3097, Civ. C1, SIGNED THIS DAY OF 19_ OWNER OR Lender's Name_ OWNERS AGENT Lender's Address ADDRESS _ I certify that I hove 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-41e above-mentioned property fa inspection purposes. gnature of Permittee �"� Date SEE REVERSE FOR EXPLANATORY LANGUAGE