HomeMy Public PortalAbout6353-6353 1/2 TEMPLE CITY BLVD_Sewer__ i
WORKERS'COMPENSATION DECLARATION 76A642D
CE B08 (280) APPLICATION FOR PERMIT
1 hereby affirm that 1 have a ce ,este Of consent to self SEWER-SEWAGE DISPOSAL
Isere, ora firm that
of Workers pee of Insurance,o
a ceyytTtipri c y there ( a ) COUNTY OF LOS ANGE ES BUILDING AND SAFETY
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❑ Certified copy a hereby furnished FOR APPLICANT TO FILL IN S CONNECTION DATA
//—/ BUILDING ��)/ STATION �/��// DEPTH
Cerlifie copY n 61ed wish t count fid nspecuo ADDR gee V A PP
de t LOCALITY MANHOLE Rg lewg NCC _074343 / LOWER
Date gpphcent �l� NgARHaT TYPH OF
CONNgC TION LENGTH r"OM
C TI ICATE OF EXEMPTION FROM WORKERS ceoeS aT v cuw. P L M L TDP L
COMPENSATION INSURANCE1 P c No (�O^
OBN.R en CO IMP NO Joe NO O }
(This section need not be completed If the work Involved MAI` D.
by the permit u for one hundred dollars ($100) or less) ADDwieae r11 DAV yPERMIT
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CITY TEL N
I certify that In the performance of the work for which this LEGAL A u O
permit Is Issued, I shall not employ any person In any manner DESCRIPTION LOT ND Hwy on or wm ENING
so as to become subject to the Workers Compensation Laws U
BLOCK TRACT 355M STATE ENCROACHMENT W
Applicant ow BLDG
PERMIT No
NOTICE TO APPLICANT If after making the Certificate of SIZE OP LOT NoN ON LOT 57
lNy
Z
Exemption, you should become subject to the Workers USE of cHwweea
Compensation provisions of the Labor Code you must forth
euILDINGe K11 L-ims
with comply with such provisions or this permit shall be coxrwwcroR `` CONNECTION CHARGE PEE
deemed revoked J
LICENSED CONTRACTORS DECLARATION ADDRESS REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter .IETNICT No N.U1 MAI ..
9 (commencing with Section 7000) of Division 3 of the Bust crcY TEL ND 1
ness and Professions Code, and m license n In full force and STAre LIC Q I� /
effect y LICENSE NO $ ,5 CLASS i �0 y '�
NO DESCRIPTION OF WORK FEE
e:�^6^coNxe<nxa To FINAL // C —,p VALIDATION
License Numbe Lic Class eo.�I. DATE
Tlc TwN
/ ar
•IT•IIMD/Ow awwlNPl.la
Contract 1 ate ow FINAL
43IVA E DISPOSAL
conn Ecnnc r. BY
❑ PwlvwT. Dlaro+wL SYSTEM
I am exempt from the licensing requirements as I am a ...111...1 EL.. OR
licensed architect or a registered professional engineer WORK TO N..SE •anew
acting in my professional capacity (Section 7051, BUS +E E1AOE 1Ir OR AIN1Iu43 v ��
mess and Professions Code) ..1.431 DNYWELL Me Y.`
REP ouvou�we Ten N
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION
I hereby affirm that 1 em exempt from the Contractors
OWNER'S Permit t
License Law for the following reason (Section 7031 5, Bust AUTHORIZATIONTOTAL FEE
Wass and Professions Code) L
I CONTRACTHAVE AT WITH TNS HEREIN HAMED C0N-
IRACTOR
THE 1uTO CONNECT TE A•OvX OKSCRiBEG�)PMTIna DWELL nD
1, as owner of the property, will do the work and the ELIC •Swan
structure is not intended or offered for sale (Section SIGNED THIS DAY OF IB ;2374.7A
7044 Business and Professions Code) OWNER
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CONSTRUCTION LENDING AGENCY nEw+ADE # is
• • • 0
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit Is 2 • • ) a 0 0
Issued (Sec 3097 Civ C)
Lenders Name
• • • 1a00�
Lender's Address 0 114 -81
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 a abov do d roperty for mspe ion ses
f^/,/T/7,// SEE REVERSE FOR EXPLANATORY LANGUAGE
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