HomeMy Public PortalAbout6213 TEMPLE CITY BLVD_Sewer__ WORKERS' COMPENSATION DECLARATION
,t 20-8051 DPW GlpS u
I hch-eby affirm that i have a certificate of consent to self
insure, or a cer!'flcare of Workers' Compensation Insurance, or 16A642D
r q.ceri,fied clip- Thereof (Sec 3800, Lab C
Policy Na 2 8.g .Company_- State Fina. - APPLICATION FOR PERMIT
Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL
_J Certified copy is filed with the county building inspection, COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date--------,-____Applicar7l.. f_:�' Q ,g_ U.Ction FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' suILUINc TATION DePrH
COMPENSATION INSURANCE ADDR�S 3`
(This section need not be completed if the work involved Cy the 4NHOJ PEFERfNCE UPPER
permit is for one hundred dollars ($100i or less ) NNEARESTTCIALITY LOWER
t.1HCfs
fvPf Of NPJECTIi>N LENGTH FROM
I certify that in the performance of the work for which this ,O Ssi Londe CURB P: M L TO P L
permit is issued, I shall not employ any person In any manner LEGAL PC No
so as to become subject to the Workers' Compensation Laws DESCHiPTION LUT,.NO. IMP No )08 NO
BLOCK (PACT 'RINK PERMIT NO ROAD PERMIT NO
Applicant _
ASSESSOR AF11DA'11' INA'✓€R EASEMFtii RECORD INSTR NC CATE
NOTICE TO APPLICANT: If, after making this Certificate of AP BOOK 26 7. PAGE rJ 7^ 8 PAecEL20168
Exemption, you should become subject to the Workers' No.OF eLDGS
Compensation provisions of the Labor code, you must forthwith SI;E OF EciT 15400 NOVUON L^,-r H.vv )R ST MDENINr
comply with such provisions or This permit shall be deemed :,)GE0P
revoked BUILDINGS STATE ENCROACHMENT
PERMIT NO
LICENSED CONTRACTORS DECLARATION rt-Tec Development Inc.
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Bu si- .1AIL 306 S .SaY1 CHARGE'
ness and Professions Code and my'license is in full force and pEiDi E'' abr1e'I' B
effect. 'p ciny Sa.n. Gabriel TEL NO. 81$ 287^336 �hJNECTICN CHAR,:E FEE
License Number 587807
L!c.CIasS J-fEIMBuRSEMENT FEE
r7-� GONTHACTCE? x"�,^-.TP,.�% COrIStXUGt_LO
Contractor Art- Tec Date Z.G-1095. DISTRICT NO GROUP MAP PROCESSED BY
ADDHt SS306 S. San Gabriel 2 BK
[J f am exempt un � ec.. ,_._..of the L-A Co. �,C}��,,� �, ;� !V.�' C�'(,_.c� �-�' a
C.ITV son. Gabriel TEL..tJG. $�:8 2 - O
Plumbing Code and/or Sec., ._ of the STAT= %AL L1
IGEN>F No.. 587807. Ass ;.)ATB VALIDATION z
B & P. Code for the follow;ng reason No. DESCRIPTION OFWORK FEE �'�' O
HOUSE.�i C NNt: NG Tp ^;A'. u
_Date— - -- E vl B Ie HIKE _ 2_0
Si TANK SEEPAGE PIT OR d
Signature _� _�__ _ P TS AND Gr DRAINFIr L �
OWNER-BUILDER DECLARATION HOUSE"-FwER CONNEc ING TO -- oilz
vR vA DISPOSAL SVSTFM
I hereby affirm that i am exempt frorn the Contractor's License ONNEi_T ADD TICINAL BLDG OR
Low for the following reason ;Sectors 7031.5, Buisness and Pro- WORK TO H•DusE SEWER
fessions Code): OVERRLOW SEEPAGE PIT DPAINFIEED
_
EXTN CESSP (X Di MANHaE
I, os owner of Theproperty, or m y employees with wages as ALTER REPAIR OR ABANDON HOUSE ACC T.
Y 9 ,Fr,Ek OR D a OSAL SvSTE.M
their sole compensation, will do the work and the structureW
---- 303 73.50
is not Intended or offered for sole (Section 7044, Business
and Professions Code) �— I I tEMS
[� I, as owner of the property, arra exclusively contracting with OWNER'S Permit $ l� i"? �' .R ' .
licensed contra tors to construct the Protect (Section 7044,
AUTHORIZATION
Eiusiness and Professions Code). TOTAL FEE �` �: : Wt `k.s
CONSTRUCTION LENDING AGENCY HAtiE AT TH'S )A A -O TRA_T w '.HE HCRE r NAME �)NiRA �.: rc � €� > II
I hereby affirm that there Is a ronstructiun lending agency c,^NNE THE AE01F.F� Br Ew�.I�Nr DNFU ING O THE PQBuc 5E'�r,FR
for the performance of the work for which this permit Is
Issued (Sec. 3897, C.Iv C.). SIGNED THIS__..— C,AY OF !.S'!
OR �t
Lender's Name 3w NE AR 0000 Ito, if"
�:WNEH AC;c!v'_ _ .__ � v. ...:A. k.
Lender's Address—______ aDD.REj "7d
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 law's regulating PII;mbng and Sewers,
and hereby authorize representatives sof this County to enter
upon the above-mentioned property tar inspection purposes.
Signature of Permittee Data. SEE REVERSE FOR EXPLANATORY LANGUAGE