HomeMy Public PortalAbout6211 TEMPLE CITY BLVD_Sewer__ WORKERS' COMPENSATION DECLARATION
f i hereto affirm ±hat 1 have a certif:cnre of consent to sell 2 -0051 DPW 6i89 u
nsure, or a cemficate of Workers'Compensation Insurance, cr 76A6420
fj j,,,fled cagy thereof (Sec. iftWfJ, Lab e ; APPLICATION FOR PERMIT
Psj�I�cy No j�.&��3_Lampary.._��c3.�,e _.�'u.I1�X.---- �p� p
Ls} Certified copy- .s hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
DareApplicant.-,Ikr-t - -c—_CcmS.tr=tion FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FPOM WORKERS' ISUILDINGS
ING STATION � DEPTH j
COMPENSATION !NSURANCE e3S �j211 �� PPER
This eetlon need not be comp�lered If the work.Irrvalved'by rhe IVANHOIE REFERENCE_fTY LOWER
perrTw isforone hundreddollars jSIW0 nr less.) TYPE Cr CONNEC�ONST Lf.NGTH FROM
I certify that in the performance of the work for which. this ,T LO deY _URB Pi �I TO P i
permit is issued, 1 shall riot employ any person in any mannerGAL_ P< NC
so as to become subject to the Workers' Compensation Laws. IPTION LOT NO. co IMP NO JOB No
TRACI TRI;NK PERMIT NO ROAD PERMIT NO
Date ApplicantNOTICE TO APPLICANT' If, after makin this Cert±f cate of OCF 7 � pAEFIDAVI WA!✓ER EASEh9[NT RFC ARD INSTR tJQ UATf
g OCrK 26L PAC36� / ���8 FSA:HCJ 6106C]3
Exemption, you should become subject to the Workers' NO.OFO D.,Compensation provisions_ of the Labor rade, you must forthwith P LOT NW ON Lot HWY OR ST d IDENING
comply with such provisions or this permi! shall be deemed Frevoked- LNGS R STATE ENCROACHMENT
t�
LICENSED CONTRACTORS DECLARATION PERMr No
I hereby affirm Thai I am licensed under provisions of Chapter OWNER AXt-rtT_ec Dgyejopmeut
9 (commencing with Section 70W0 of Div!sion 3 of the Bu si- MAti. S
Hess and Professions Code, and m�!Itcense is in full force and ADDRESS 3 0 6 S. Sall � hr i P� ]l VCS CHARGES
4 effect GI?Y a Gb TEi_.NC. "N"c_f_'C'fA RGE FEE
= 58780_
License Nur}b.er �_Lic. Cioss_____B REIMBURSEMEN'FEE
Art4t; DONT HAGTOR —T�(�'' DISTRICT NO GROUP MAP PROCESSED BY
conLj tractor Cols^sect Dole. 10-10-95 x306 S. San Gabriel .� �. }
��71 ADDRESa BK
am exemp un�er sec of the L.A. Co.
CITY San Gabriel el EL No (.818) 287-3366 ` ' 3!" C�j `
Plumbing Code and/or Sec _ef The STATE LIC. L t:,Nk �
LICENSE NO 587807 A ?ATE VALIDATION z
B. & P, Code for the following reason__ ria, DESCRIPTION OF WORK FEE I'f O
HOLSF SEWER CONNECTING TC, FINAL (�
Dote PuB,C SEWER , :`) By (�
U
SEPTIC TANK SEEPAGE a T OR LU
Signature P T$ArJ OR GRA NF E
g azure HOUSE SEWER C NNEC Ire- TO
— , N
3c a, OWNER-BUILDER DECLARATION RVA,E vSPCSn Y5r M Z
1 hereby aff,rn-1 that I am exempt from the Controcrar's License LVNNECT ADO,noNAL BLDG OR
r law for the following reason (Sector 7031.5, Buisness and Pro- WORK To H. SE SEWER
d
VERFLOW SEEPAGE FIT 3RAINFIE.0 ,} v
f f'551airs Cade): F%iD CES PUO DRYWLLL.MAN
H(llf.
I A TER REPAIR OR ABANDON HOi iSE. n.�• ,tt„
I as owner a-f fhe properly, ar my erlplayees with wages as „- . . ,
`. _EWER.,H(}iSPC}$AL.SYSTEM
�a their sole contpen<_otion, will do the work and ±he s ;rture
is not intended or offered for sole (Section 7044, Business _ 3303 =L&'Al
and Professions Code). ITEMS
as owner o the property am exclusively con!racting wish &
r]
�.. Permit ..licensed contractors to construct the proieet Section 7044 f.T # v
Business and Professions Code, AUTHORIZATION TOTAL FETE c;`J
COhSTRl1CTl(?tJ LENDINi, AGENCY I eavE AT THIS DATE A c atva r .v tr HF FiEREIry NAWLC,)NIRA T
r
. Df i.;'RiBf Eh 7iM JA c;I,INL �� rF P'J6�l R TE
hereby affirm rmthat there �s o construe°{on lending agency CONNECr THE AB JE
ry for the performance of the work for which this permit jS
Fair.: issued (Sec. 3047, Civ. C ; S1 G"41.D THIS DAY(:)F
.. Wvr,tw OR
d `T rrcvM
Lender's Name JWNEF AC;ErJi f�l3�#'t`3—S=.N#a 3. .�.II�.I�.�2 :.._r
ADF,RESS _
Lender's Address �__ --� 2'774 1 A"E°t,_1,;1"3,
I certify that I hone read this oppi Caton and state that the
L 'above informatictn IS correO. 1 agree to Crjr-nply with all CO lr,!V
ardirronces and Stole laws regulatf-tg .Piumbinq and Sewers,
Oil hereby
out representat ves )f this County to enter
`. upon the above-mentieoed property flif nsptrtion purposes.
r
' Signature of permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE