HomeMy Public PortalAbout6209 TEMPLE CITY BLVD_Sewer__ WORKERS' COMPENSATION DECLARATION
I ,hereby[ffirr% that I Aove a certlficote of Consent to self 200051 1)PW 6x89
insure, or a certificate of Workers'Compensolion Insurance. or 76A642D
a Fertified copy thereof (sec 3800, Lal APPLICATION FOR PERMIT
Policy Na. __l16-8437S7,pany__ State -Fund SEWER - SEWAGE DISPOSAL
Certified ccapy is hereby furnished.
iCOUNTY OF LOS ANGELES BUILDING AND SAFETY
(_1 Certified copy i5 fried with !tTe cot;niy t, .i!ding inspection .
department.
Date_—_- _Applicant-A -t—' -e—c--Capt-ruiction FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING6 09 Tent le (� STa. io �r .� DEPTH -�
COMPENSATION INSURANCE ADDRESS Tv b
(This section meed not be completed if the work involved by the .MAN'H�OLE REFERENCE UPPER
L
permit is for one hundred dollars ($IClOCAI ITY OWERN)) or less_j Or CONNECTION
NFAREi, LENGTH fRGM
I certify that in the performance of the work for which this c-oss s, Londen Y CURB PL M: TOP(
permit is issued, 'I shall not employ any person in any manner r`
IEu ,_ P: No
5Q as to become subject to the Workers" Compensation Laws. DESCRIPTION .uT NO. ;Mr NO JOB NO
BLOCK TRACT R„NK 7.O POAJ PERM'T 140
Date__ Applicant_—.__,___
NOTICE TO APPLICANT: If, after making his Certificate of AS'SEs;I'R AFF;cA wA:vez EASEMeryT REcgPD IrJSTR No PATE
g MAR BOOK26,
PAG'r P.^.7„rl_
Exemption, you should become subject to the Workers' q NO OF B �
Compensation provisions of the Labor code, you must forthwith SIZE OF;-pr 15400 Now ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed usE Oa _.
revoked. GUI,"DINGS STAT€ENCROACHMENT
PERMIT Nic
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter OWNER Art-Tec pee t 0 J�CIe Inc.
9 (commencing with Section 7000) of Division 3 of the Busl- MAIL �' S. Gabriel CHARGES
ness and Professions Code, and my license is in full force and AE'i;F;Ess
effectcity san Gal2riel TEI.NG'. CONNECTION CHARGE.FEE
License Number ^LiC.Class $___ RE,.MBURSEMENT FEE
CON �A CrOI-I Art-'Tec Co DISTPICT NO CROUP MAP PROCESSED By
Contractor_ Ar'�'j'_�o _.,_..Date_�Q,�-Q,,,.9 5 - AnlTl�tS, 3 0 6 S S � e� 'G
Cons�r�.ction r
❑
[am exempt un er ec __. _ of the L.A.Co. CITY San Gabriel TEL NO $] _ _.�' b - cit�-. 70 n-
Q
Plumbing Code and'or Sec of the STATE J, F'NAL 1 V
c.NaE' : cj 8 78 0 7 s DATE i r 1-� p VALIDATION Z
B. & P. Code for the following reason_ No. OEscRIPTiON OF WORK FEF 1 i+
Ho JSE 6FWER C-ONNEC'INC-TET F.NAL 1—
Date BL!C SEWER '� �.t,,+ By U
SEPTIC TANK SfEPAGE PIT OR UJI
SSignature _.� _ S AN'_1 f R RAINa ELIi �
OWNER-BUILDER DECLARATION t SENrR c.NN nc TO ® Z
_ ✓R ATF[ SPl SAI S 5 tM
I hereby offirm that I am exempt from the Contractor's 'License n J€C A D CNA e GG OR
Low for the following reason (Sector 7031 5, Buisness and Pro- OO(TOH) FVFR
fessions Code): vF F^,W SEEPAGr DRA�NF c J. _
F TNl ,E POG i C�.
DPYWELL V-NLF _ ,g,
A TER REPAIR OR A,BANDC`N HOUSE C s'
.J 1 as owner of the property, or my employees with wages as EWER OR�,sPOSa�, r tM .,-•,, -r 73.50
y; +.
their sole compensation.will do the work and the structure - ,".a1 ;. .�
is not intended or offered for sole (Section 7044. Business LL��
and Professions Code). I Ere
I,
r as owneof the property, am exclusively contracting with 1I.ITA -73 .50
licensed contractors to construct the prosect (Section 7044, OWNERS Permit $ � '� D
Business and Professions Codel. AUTHORIZATIONTOTAL FEE "( `fj (C H1: K3.5
CONSTRUCTION LENDING AGENCY I HAVE AT TFr,, fATE A ccs TRA ✓ Ta E HERE NAM,() R
CONN'U T THE Ar'Cw€.EY_R PED EXIs w .,Nr THF' 'Fv.:.,t CHANGE 14".r._1I
I 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,), SIGNED THIS f_I,AY 01`___1 9_
_--
)INNER OR
LendeName OWNFRSAGENT --- O„ ul"S # 10/12195
_
ADDRE55 __ J
Lender's
I certify that I hove read this application and state that the
above information ;s correct. I agree- to comply with oil County
ordinances and Stott- laws regulating Plumbing and Severs,
and hereby authorize representatives of thus County to enter
upon the above-mentioned property for inspection purposes.
Signature ofPerm ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE