HomeMy Public PortalAbout5953 TEMPLE CITY BLVD_Sewer__ WORKERS'COMPENSATION.DECLARATION
` erertificate of consent to self
eby trffirm that I have a c
inWte, or'o certificate of Workers'Compensation Insurance, or 70A642D
a certified copy thereof (Sec. lab C. CE 808(REV.8'81) APPLICATION FOR PERMIT
Policy Na. Companyny 4%
El-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.
Date_ Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING E, 7
COMPENSATION INSURANCE ADDRESS _:V 3 .j-W#4,K 1C I/ f' ^LVO STATION DEPTH
(This section need not be completed if the work involved by theUPPER
permit is for one hundred dollars ($100)or less.) LOCALITY f MANHOLE REFERENCE LOWER
I certify that in the performance of the work for which this NEAREST , !d /,, TYPE OF CONNECTION LENGTH FROM
CROSS ST. ./! V � , ¢,. Y. CURB P.I. M,I.TO P.L.
permit is issued, I shall not employ any persq�njnkerTy'manner
so as to become subject to the Wa s G pensgfiofr taws:' OWNER f F%; ! �ij CO IMP.No. Poe nN0
y ..-!;"a�,��"�` MAIL ... n
} TRUNK PERMIT NO. ROAD PERMIT NO.
Date-__ —ApplietSnt , ' _' — _. ., ADDRESSC)
NOTICE TO APPLICANT: If, after makingthis Certificate o{ 6 AFFIDAVIT WAIVER EASEMENT RECORD, NSTR.NO. DATE
CITY , ( ,TEL.NO, -t, �''T .-�,�� `- f..,f
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. <- HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed —
revoked. BLOCK TRACT �,% 57 STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION p PERMIT NO.
DECLARATION if NO.OF BLDGS. X,,°!. �,
SIZE OF LOT -U Ui„f I< ', NOW ON LOT -
I hereby affirm that I am licensed under provisions of Chapter usE "
9 (commencing with Section 7000) of Division 3 of the Bu SI- of
BLIILOF CHARGES
ness and Professions Code, and my license is in full force and _
effect. ��+j e�
CONTRACTOR ��.�... �> r �. �,� � i!� �,� "' CONNECTION CHARGE FEE
License Numbedf � d
R I - ADDRESS ,� „ REIMBURSEMENT FEE O
`_y . DISTRICT NO. GROUP MAP PR ESSED BY u
Contrpc - _ Date ! CITY TEL.NO. <$0 K 6 f} a '
'- BK PG C Z
STATE LIC. O
❑ I am exempt under Sec, of the L.A.Co. ucENSE NO. `! ) CLASS L._ \ V
Plumbing Code and/or Sec, of the NO. DESCRIPTION OF WORK FEE FINAL PUBLIC SEWER VALIDATION oW.
HOUSE SEWER CONNECTING TO s� DATE
B. $ P. Code for the following reason l Z
SEPTIC TANK,SEEPAGE PIT OR FINAL J
.PITS AND/OR DRAINFIELD By
FIV
NAL
HOUSE SEWER CONNECTING TO fr,/�
Si nature PRIVATE DISPOSAL SYSTEM ✓ -�f g, ��
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWERJ0.
hereby affirm that I am exempt from the Contractor's License E TNF,LOW CESSPOOL.DRYSEEPAGE w DRAMAN OLE
Low for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
Ll I,CIS Owner of the property,or my employees with wages as
their sole Compensation, will do the work and the structures ,� A
is not intended or offered for sale (Section 7044, Business &�.
and Professions Code). OWNER'S Permit $ p
L] I,a +s Owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE � ,' ,j /
licensed Contractors to construct the project (Section 7044, i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO m -1 7, 5 0 G
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY �— 0 6 1 0-87
I SIGNED THIS A .,--' DAY OF o��-r�` t� ►
hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT ....,.- .-
Lender's Name 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 outhorize rgpie�sentatives of this County to enter
upon the above- toned pr-Qpafty'f6rr-inspection purposes.
Sign0t,re of Perrnittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE