HomeMy Public PortalAbout6355 TEMPLE CITY BLVD_Sewer__ WORKERS COMPENSATION DECLARATION 7SA642D
CE 808 (2 Bo) APPLICATION FOR PERMIT
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SIu'I
I hereby affirm that 1 have a certificate of consent to self SEWER-SEWAGE DISPOSAL
Insure or a certificate of Workers'Co nsation Insurance or
nP9ryf15dCn y t o�(�Se� Le C ) Cf COUNTY OF LOS ANGEL(�e BUILDING AND SAFETY
f❑oLECetrtl�fied copy u hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING lTwrloN OC� DEPTH
Cert a cop n filed with th coun d 1 .Gran Alaoweee ------
de LOCALITYMANHOLE REFERENCE 3v / LOWER
Date Applicant NEARESTTYPE OP CONNECTION V LENGTH OM
CE TI ICATE OF EXEMPTION FR M WORK c.o¢¢ ST r eu.a P L M L TO R L
COMPENSATION INSURANCEPC no _
OWNER CO IMP NO JOB NO
MAIL a
(Thu section need not be completed If the work involved ADO.ESS 4fmoaTRONR PERMIT NO ROAD PERMIT NO O
by the permit Is for one hundred dollars ($100) or less) !taw A.r,D.vIT W,vvv. ew.olENr . cO.D IN.TR N DATE U
CITY HL N
I certify that m the performance of the work for which this LEGAL
Permit is Issued, I shall not employ any parson In any manner DESCRIPTION LOT no
so as to become subject to the Workers Compensation laws NWY OR ST WIDENING U
FLOCK - TRACT STATE ENCROACHMENT uj
Data ApplicantNo oP Loo• PERMIT NO 1
N
NOTICE TO APPLICANT If after making this Certificate of SIZE OF LOT NoW ON Lor Z
Exemption you should become subject to the Workers ua¢ OR GRAB Sea
Buuo 1.2!
Compensation provlswm of the Labor Code, you must forth
with ,comply with such provisions or this permit shall be ��7 ....¢cT ION ...... ..a
deemed revoked conr.weroR
. LICENSED CONTRACTORS DECLARATION ADDRESS REIMBURSEMENT PEE
I hereby affirm that I am licensed under provisions of ChapteroL+.ICT No ..DDI AlMPwoc E. Er
9 (commencing with Section 7000) of Division 3 of the Bust crcr TEL �/
ness and Professions Code and my licensers in full force and STAT 71 IC �Od
effect uc¢NSE No CLAee
KO DESCRIPT O OF WORK FEE
License Number LIc Class "ru°e��::N:".CONNECT'.T T RIVAL / / 9 VALIDATION
DATE
II.I..T N ....... r
CODtracto I Date NO/ow Nnrtc FINAL
❑ rR lv w T.DASA coL ,IT.. ro EY
{rO.wL tYtT.Y
1 em exempt from the licensing requirements as I am a CO MUCT ADDITIONAL.Loc OR 7
licensed architect or o registered catered p(Secti tan? engineer wo.R TO H E AGE.. /
acting d my professional capacity (Section 7051 Bus OvTN Lo.. PAGE P,. O.uxnuO -G/
exrN DL ewYW.. O..E
meas and Profesvons Code) wLTEw c OR wEwx.DN Nova ®/9
mwe. o vmAL.T.T.. 6--
LIc or Reg No Date
HOMEOWNER BUILDER DECLARATION I ;23 7 4,8 A
I hereby affirm that I am exempt from the Contractors OWNER'S Permit t # 0
License Low for the following reason (Section 7031 5, Bust AUTHORIZATIONI TOTAL FEE
ness and Professions Code) DATA w CONTRACT WITH T RUN .wM co con- 2 0 0
❑ 1...T`O.TO conn.cT Tx.weov. Da....... Enna DwRu,Na
I, as owner of the property will do the work and the ro THE Pv.LIc ...C. • • • a 0 0
structure is not Intended or offered for sale (Section SIGNED THIS DAY of la
xu
7044 Business and Professions Code) OWNER 0*
M.N01 14-81
..OQMT
CONSTRUCTION LENDING AGENCY
•oowco
I hereby affirm that there Is a construction lending agency
for the performance of the work for which this permit Is
Issued(Sec 3097 Civ C )
Lender's Name r
Lender's Address
I certify that 1 have read this application and state that the
above information Is correct I agree to comply with all County
ordinances and Slate laws regulating Plumbing and Sewers
and hereby Sotho a repre".tatives of this County to enter
upon t (above Io .party for mspec Ion purposes
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
I
tgnature o etmtttee D e