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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