HomeMy Public PortalAbout6042-6044 TEMPLE CITY BLVD_Sewer__ WORKERS'COMPENSATION DECLARATION
I `I@reby affirm that I have a certificate of consent to self
ire. or a certificate of Workers'Compensation Insurance, or '6A642D
ertified copy thereof (Sec. 3800, Lab C.) +E808(REV.8/81) APPLICATION FOR PERMIT
licy No. Compony is
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 2?C'J711_4 e(11-IrFOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS'
FA
ING -r�t a�'
�„")"II Lz /�rAy t� L�"' -o� STATION e< DEPTH
COMPENSATION INSURANCE ess ,�.
(This section need not be completed if the work involved by the7 ,y,�, MANHOLE REFERENCE fir- s '� PER
permit is for one hundred dollars ($100) or less.) NEAREST
LOCALITY t �` t r`
OM
I certifythat In the performance of the work for which this ST TYPE OF CONNECTION M L TO P L.
p S ST. Y CURB P.L. � M.L,TO P,L. �
permit is issued, I shall not employ any person in any manner /p /� P c Na
so as to become subject to the Workers' Compensation Laws. ER A c. JM SIG CO.IMP.NO. - /" JOB NO.
MAIL
r�
Date Applicant
ESS a �' �'`+'�' `BB. ft'rr 6 S Q TRUNK PERMIT NO. �4' OAD PERMIT NO -
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR NO DATE
NOTICE TO APPLICANT: If, after making this Certificate of TEL.NO. C 3:5 C
Exemption, you should become subject to the Workers' ALCompensation provisions of the Labor code, you must forthwith IPTION LOT NO. - HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemedrevoked. TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS .ERMIT NO.
F LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter F9 (commencing with Section 7000) of Division 3 of the Bus'- INGS fC f' ' CHARGES
ness and Professions Code, and my license 's in full force and g f
effect. CONTRACTOR ,QJ— P'b1 �.('Sq, ?�C. d`c:,tis7 CONNECTION CHARGE FEE
License Number .212-'- 1 / Lic. Class � 7ADDRESS IU 'V?>Z `�-r,.�-�j" �' J'�' REIMBURSEMENT FEE
Contractor • ' " """"` Date DISTRICT NO. CROUP MAP PROCESSED BY
CITY s.eJ Lw '- IV-K, TEL NO. '
STATE C' LIG ,, � BK— PG
I am exempt under Sec. of the L.A.Co. LICENSE NO. �d ° CI.ASs [: Ic� ��tf �
.
Plumbing Code and/or Sec. of the NODESCRIPTION OF WORK FEE/ HOUSE SEWER CONNECTING TO �. DATE ( VALIDATION
B. & P. Code for the following reason PUBLIC SEWER }
SEPTIC TANK,SEEPAGE PIT OR FINAL
FITS AND/OR DRAINFIELD
Date HOUSE SEWER.CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature A& CONNECT ADDITIONAL BLDG.OR ►
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
hereby affirm That I am exempt from the Contractor's License EkTN.,CESSPOOL,DRYWELL,MANHOLE fel I� �R`" 7 ✓✓
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 $ /9,IM
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE
licensed contractors to construct the project (Section 7044, HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY 01111.for the performance of the work for which this permit is A
I
hereby affirm that there is a construction lending agency SIGNED THIS vj DAY OF � J'"4Z 19
OWNER `tee
OWNERS AGENT
.Issued (Sec. 3097, Civ. C.).
ADDRESS
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 regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
Y3
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE