HomeMy Public PortalAbout6029-6031 TEMPLE CITY BLVD_Sewer__ WORKERS',COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D U
o certified copy tF reof �. 3800, Loob�C., --- CEB�BIREV ,,891 APPLICATION FOR PERMIT
Policy No��Cany 'z�6LC
❑ Cert' ied copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
dep rtrr)e .,�
Date= ,t� Applicant �IllL' ?�". FOR APPLICANT TO FILL IN CONNECTION DATA
�.. FICA E OF EXEMPTION FROM WORKERS' BUILDING
COMPENSATION INSURANCE ADDRESS 6►ry E it srAnoN DEPTH .!
(This section need not be completed if the work involved by the ' MANHOLE REFERENCE d11-ER
permit is for one hundred dollars ($100)or less.) LocAUty ? �! }c>
I certifythat in the performance of the work for which this NEAREST �. -p TYPE OF CONNECTION ML LENGTH FROM P CROSS ST P' Y. g P 1. ML.TOP1.permit is issued, I shall not employ any person in any mannerso as to become subject to the Workers'Compensation Laws. Pc NoOWNER C C`.�' CO.IMP.NO. !OB NO.
one
MAIL �. TRUNK PERMii NO. ROAD PERMIT NO.
Date Applicant ADDRESSNOTICE TO APPLICANT: If, after making this Certificate of CITY I�$,ki - l/6 TEL NO. C; AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO. G
Exemption, you should become subject to the Workers' LEGAL ��J G
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 STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION No OF BLDGS / PERMIT NO
y P P SIZE Of l0TNOW ON LOT
I hereb affirm that I am licensed under rovisions of Cha ter USE OF ..
9 (commencing with Section 7000) of Division 3 of the BUST- BUILDINGS W CHARGES
ness and Professions Code, and my license is in full force and
effect. CONTRACTOR Ipf'— CONNECTION CHARGE FEE
License Number Lic.Class ADDRESS ` ,p �x / REIMBURSEMENT FEE
COMraCfO( Datexr-� �T DISTRICT NO. GROUP MAP PR ESSED BY 0
CITY g TEL.NO. �4' ` (T /
STATE LIC. �j .�f BK PG U
❑ I am exempt under Sec. Of the L.A.Co. LICENSE NO. CLASS lc�.� / w U
t/ f�. GG
No. DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the HOUSE SEWER CONNECTING TO DA EL L- VALIDATION O
PUBLIC SEWER _ U
B. & P. Code for the following reason RSEPTIC TANK,SEEPAGE PIT OR W
PITS)SND/OR DRAINFIELD FINAL LC
U6
Date HOUSE SEWER CONNECTING TO BYZ
PRIVATE DISPOSAL SYSTEM �-
Signature t CONNECT ADDITIONAL BLDG.OR ,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
1 hereby affirm that I am exempt from the Contractor's License EXTN.,`CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ 1,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit S a �}
❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE '`
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT A R TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUFILIC SEWER.
CONSTRUCTION LENDING AGENCY —� t
1 hereby affirm that there is a construction lending agency SIGNED THIS----, (-— OF t _l ►
for the performance of the work for which this permit is OWNER OR y
OWNERST
issued (Sec. 3097, Civ. C.). Gf�
ADDRESS i7 '-11W2 e
Lender's Name
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 regula g Plumbing and Sewers,
and hereby authorize repr ent 'des of this County to enter
upon the v -mentione pro rty for inspection purposes.
^ .
nature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE