HomeMy Public PortalAbout6356 TEMPLE CITY BLVD_Sewer__ WORKERS COMPENSATION DECLARATION
I hereby affirm that I have o certificate of consent to self 92�DPW 31W
Insure a a lertificute of Workers'Compensation Insurance or 1�
y''No`��=��rs�'�a a" '&i'Ins. Co. ®a" APPLICATION FOR PERMIT
Poli❑ Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL
�1 Certified copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date t la Applicant Omen Bros Pl iambi ng FOR APPLICANT TO FILL IN CONNECTION DATA
kTFZ OF EXEMPTION FROM WORKERS' euILdNG
COMPENSATION INSURANCE Amass 044 STATION DEPTH
(This section need not be completed If the work Involved by theMANHOLE IrEI£REEJCE uwER
permit Is for one hundred dollars ($100)or less ) LOCALITYL
I certify that In the performance of the work for which this cRoss sT WPE OF CONNECTION LENGTH FROM
permit is Issued, 1 shall not em IO an Y CURB PL ML TOPL
pe p y y person m any manner PC No
so as to become subject to the Workers'Compensation Laws aWrasLOUAIW m IMa NO JOB NO
MAIL �I, TRUNK PERMIT NO ROAD KRMIT NO
Dote Applicant ADDS -✓
NOTICE TO APPLICANT If, after making this Certificate of �. TEL I AKIDAVIT WAIVER EASEMENT aCORD INSTR NO DATE
Exemption you should become subject to the Workers'
Compensation provisions of the Labor code, you must forthwithI7E-SLECP OLJ Lor No
comply with such provisions or this permit shall be deemed HWY OR ST vnDENIIVG
revoked BLOCK TRACT STALE ENCROACHMEM
LICENSED CONTRACTORS DECLARATION No OF atDGs KwMr IW
I hereby affirm that I am licensed under provisions of Chapter USE OF LOT NOW ON Lor
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDIDINGS CHAIICWS
nese and Professions Code, and my license Is in full force and
effect CONTRACTOR CONFECTION CHARGE FEis
E
�c 0
License um er 771 /.1 LIc Class, -i-V— ADDRESS 4265 N. Baldwin Avenue REIMBURSFMENT FK 0
5 (o- 5 1 pit El Monte m No 443-0078 DISTRICT NO GROUP MAP IMOCfSSED BY 0
Contractor Olden EI'08. pore EK _
❑ I am exempt under Sec of the L A Co i MISE NO 231 741 USS C 6-20-16 �� _3 O
RK WOFEE
NO DESCRIPTION OF ()
It-
Plumbing Code and/or Sec of the HNAL
HOUSE SEWER CONNECTING TO DATE VALIDATION W
B 8 P Code for the following reason PUBLIC SEWER
SEPTIC TANK SEEPAGE PIT OR Pin =
HTS AND/OR DRAINFIELD
( Date HOI SEWER CONNECTING TO BY
PRTVA
Signature CONNECT ADDITIONAL BLL O Oft ►
OWNER-BUILDER DECLARATION WOOVEaLOW PAGE PIT DRAINFIELD
RK To HOUSE SEWER
I hereby affirm that I am exempt from the Contractor a License DAN CI DRYWELL MANHOLE 11_
Low far the following reason (Secton 7031 5 Bulsness and Pro- ALTER KPAIR OR ABANDON HDUSE
fencim Code) I SEWER OR DISPOSAL SYSTEM AP-T.4
❑ I,as owner of the property,or my employees with wages as
their sole compensation will do the work and the structure
is not Intended or offered for sale (Section 70", BusinessI ITEMS
and Proien,ons Code) OWNER'S Permit S
❑ I as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE I OTnL 66 . 5:
licensed contractors to construct the project (Section 70" 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CHECK 5b.r_
CONSTRUCTION LENDING AGENCY -performance of the work for which This i_t?flN']E ,IJfJ
L
hereby affirm that there Is a construction lend mpermit Is g agency SIGNED THIS DAY OF 19_
for the OWNERM
OWNERS AGENT
Isauad (Sec 3097, Civ C )
Lender's Name A Di1Ess 00011-01101 51 7/5-
Lenders Address lug 1 Ah 7'291
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,
I
d here authorize representatives of this County to enter
X-9
the above mentioned property for Inspection purposes
a ure of Permittee at SEE REVERSE FOR EXPLANATORY LANGUAGE
1