HomeMy Public PortalAbout6351 TEMPLE CITY BLVD_Sewer__ WORKERS COMPENSATION DECLARATION D
CE 808801
APPLICATION FOR PERMIT
CE 808 D
1 hereby affirm that I nave a car ficate of consent to self SEWER-S EWAG�., DISPOSAL
Insure, or a certificate of Workers'C mpensatmn Insurance or ��
,g�(pteltifteo y thereof c 380 ab ) COUNTY OF LOS ANGE ES BUILDING AND SAFETY
cy IVdl
Certified copy is hereby furnished FOR APPLICANT TO FILL IN ,1 CONNECTION DATA
BUILDING STATION Jt DEPTH
ADDRESS
(/ IPes
Cer fi copy Is filed with th count 1 spectionuly t 3
d0 fl
t LOCALITY MANHOLE REFERENCE _o 3O LOWIR
Date Applicant NHASMSE TYPE OF CONN.CTION L...TH IRO.
CE TI KATE OF EXEMPTION FROM WORKERS enosa ST f r CUR. I L M L TO P L
COMPENSATION INSURANCE F C No
OWN.p GO IMP NO JOB No
MAIL }
(Thu section need not be completed if the work involved AOOR... TRUNK PERMIT NO ROAD PERMIT NO
by the permit is for one hundred do0ara ($100) or less) AFFIDAVIT AIV ooRo IN.T. H DATE a
CITY TEL n O
1 certify that In the performance of the work for which this LEGAL L)
Permit Is Issued, I shall not employ any person in any manner DESCRIPTION Lor No
HWY OR ST WIDHNIND O
so as to become subject to the Workers' Compensation Laws
BLOCK •� TRACT STATE ENCROACHMENT
Date Applicant NO OF pLD 03 PERMIT NO
NOTICE TO APPLICANT If after making this Certificate of SIZE OF LOT NOW ON Lor
Exemption you should become subject to the Workers use OF .. rRIMIh\U cnwpa¢s Z
Use
Loinas
Compensation provisions of the Labor Code, you must forth
with comply with such provisions or this permit shall be CONNECTION CHARGE FE!
deemed revoked corvrpwerOR
LICENSED CONTRACTORS DECLARATION ADORES
t REIMBURSEMENT F¢¢
I hereby affirm that I am licensed under provisions of Chapter STRICT n Rou MAF .o.
9 (commencing with Section 7000) of Division 3 of the Bust CITY L no
ness and Professions Code, and my license is to full force and Srwre LIe /_
effect t iclNse No cues / �/ ((/
�/t 40
NO DESC PTIO OF WORK FE!
License Number / Lic Class �+.uc.EW.n FINAL l_ /� J/ VALIDATION
EW.R .....cnpO To DATE f a
SEPTIC TANK .REFAOR PIT OR
Contractor Date IT.Ano/D. .".IH I... FINAL
..........C....CTIN.TD.FovRy
ElCT ADDITIONAY•ELM
I am exempt from the licelicenrequirementsCON
U
licensing requirements as I am e o ON I architect or a registered professional engineer o HOUSE SEWER
acting In my professional capacity (Section 7051 Bus YHIL.W...I...FIr on wixrl.LD O,ti.Gp' f'�oC
mess and Professions Code) ....
AIR OR DAY. 11 HOUSE .
Neo.HOUSE
a ALTER Dw DurouL iv.r.M
Lic or Reg No Date
HOMEOWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors OWNER' S Permit f
License Law for the following reason (Section 7031 5 Bust AUTHORIZATION TOTAL FEE
ness and Professions Code) AT TNI. DATK w CONTRACT WITH T NAMED COR-
w..Ton T H. ...R. THE
H WGLuna
1 as owner of the property will do the work and the THS Fu.". .EWER
structure IS not intended or offered for sale (Section SIGNED THIS DAY OF 19 Z C ) /I
7044 Business and Professions Code) OWNERsJ J A
CONSTRUCTION LLNDING AGENCY D..9 AGE # ' • . • ) 0
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is - 21• . ) a 0 0
Issued(Sec 3097 Civ C)
Lenders Name ,. • • 1 a 0 0 QX
Lender's Address 0 1 1 4 _8 1
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 laws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon the veli a Ia raper[y for inspeL//��I/{o('n//��P�u{rJ,/lposes SEE REVERSE FOR EXPLANATORY LANGUAGE
�gne[ re o ermrtte D�y /