HomeMy Public PortalAbout6349 TEMPLE CITY BLVD_Sewer__ WORKERS COMPENSATION DECLARATION CE 808 (2 APPLICATION FOR PERMIT
1 hereby affirm that 1 have a certificate of consent to self SEWER-SEW E DISPOSAL
Insure or a certificate of Workers C nution Insurance, r
yawcern0ad cop ter t(5 ab C) �/^ ��' COUNTY OF LOS AN LES , BUILDING AND SAFETY
'ICY N erebyfa
�rtlfied copy u hereby furnished //—/—�/ FOR APPLICANT TO FILL IN CONNECTION DATA
BOILDINa STATION �-Q/ DEPTH
Cert h copy Is filed with[h a nt dl pec[lon AOORe Ti
UPR
de LOC ALIT MANHOLE REFERENCE /,,L00 /O' -L==L=.OWSR
Date Applicant NSA--.T YPR OF CONNECTION LENGTH O
C 7 KATE OF EXEMPTION FROM WOR CRo.a IIT r CURB IL M L TO P L
COMPENSATION INSURANCE. PC NO
OWNER CO IMP NO JOB NO
(T N
(Th19 9aCflOn need not be completed If the Work IIIYOIVCd AAIL
DDRESS TRUNK PERMIT NO ROAD PERMIT NO
by the permit t9 for one hundred dollars (5100) or leas) AFFIDAVIT I WAIVER IMAJIMMENrIA.C.RD I..TN NO DATE a
CITY igAA W" reL n — O
I certify that In the performance of the work for which this LEGAL U
permit Is Issued, I shall not employ any person In any manner DESCRIPTION LOT NO
so as to become subject to the Workers Compensation
OR IT WIDENING on Laws Q
FLOCK� TRACT :�YGSSMSTATE ENCROACHMENT 1—
Date Applicant No oP eOLit PERMIT NO
NOTICE TO APPLICANT If, a (�
T
fter making this OF LOT NOM ON Lficete of d
Exemption you should become subject to the Workers' USE OF cllwlraee N
Compensation provsstons of the Labor Code you must forth
euuolNas Z
with comply With such provisions or this permit shall be ....KCTION cHARGS PEE
deemed revoked colvrR we row
LICENSED CONTRACTORS DECLARATION ADDelreXffi REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter DISTRICT no ceouF Mw Fw oc Seo BY
9 (commencing with Section 7000) of Division 3 of the Bust clTr TEL N • FD
nese and Professions Code and my license Is in full force and STAT LI �� J
effect ueeNaE RO cu•S 6
NO DESCRIPTION OF WORK FEE
I FINAL / _ rVALIDATION
License Numb Lie CDATE lass Fes:�I�.::::Conn.CTIXc To j O
gin.c TAH. ...PAG. Fir o
ARD/Ow .FI.LO
Contracto afe R FINAL
ou...a R.n SAL HH.cnHG TO B,, _
O
' am exempt from the licensing
.DISY.T.M
cenng requirements ea 1 am a e.. II.T.
DDITIOnG on
licensed architect or a registered professional engineer WORK To HOUSE SEWER 112
acting In my professional capacity (Section 7051 Bos oven FLOW.EEPAG. P
mess and Professions Code) .00L DwY�NDO� I�
AL MR eISPOSAL SYSreln�AHOUSESEWER OR
Lie or Reg No Date-
HOMEOWNER
ateHOMEOWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors OWNER'S Permit t
License law for the following reason (Section 7031 5 Bust AUTHORIZATION TOTAL FEE
ness and Professions Code) , DATA A CONTRACT W HER. w X.It con
❑ RACTOR TONCONNECT THE ABOVE DESCRIBEDuuTlna DRcwna
1 as owner of the property will do the work and the .o THE F Buc -93750A
7 O A
structure Is not Intended or offered for sale (Section SIGNED THIS DAY OF III
7044 Business and Professions Code) OWNER • B B . 1 0
OWNER....
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency 2 • • 1800
for the performance of the work for which this permit IS s
issued(Sec 3097 Civ C) • • IS 1 8 0 0 0
Lender's Name
0114-81
Lender's Address
I certify that I have read this application and state that the
above information D correct 1 agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers
and hereby author ere re entatives of this County to enter
upon t above a roperty for Inspects n pu poses
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnatu a of Permittee Dat