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Home My Public Portal About6357 TEMPLE CITY BLVD_Sewer__ WORKERS COMPENSATION DECLARATION 76AB42D CE 808 (2 80) APPLICATION FOR PERMIT I hereby affirm that 1 have a certificate of consent to self SEWER—SEWA E DISPOSAL Insure or a certificate of Workers Compeq tion Insurance,or a certifi th 3 ab III! j COUNTY OF LOS ANGE S BUILDING AND SAFETY PohcXrwp �( ❑ rtified copy Is hereby furnished // �� FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING STATION D DEPTH Cert ed copy is filed with the ou I n ection woowcaa Iy — de t uP Date Applicant LocwurY MAnxol.e w¢F¢w¢nc¢ .J.DD �� NBARBtT TYPE OF CONNECTION LENGTH F M Ch TI KATE OF EXEMPTION FROM WORK cwoaa ar I cuwe PL M L To P COMPENSATION INSURANCE 1 PC No DO�Q OWNER CO IMP NO JOB NO T MAIL a `.hu S tion need not be completed If the Fork mvo4ved A...... TRUNK PERMIT NO ROAD PERMIT NO O by the permit ts for one hundred dollars ($100) or less) CIT16 A TEL N FFIDwvI . ...... IN•T. w0 AT. U I certify that In the performance of the work for which this LEGAL .l Q permit IS Issued, I shall not employ any person in any manner I RIP NOR LOT No NWv OR ar WIDENING so as to become subject to the Workers' Compensation Laws U BLOCK TRACT STATE ENCROACHMENT LU Date Applicant PERMIT NO N PP SIZE OF LOT NOWDOIiBLOT S NOTICE TO APPLICANT If after making this Certificate of Z Exemption, you should become subject to the Workers' ua¢ oP CHARGES Compensation provisions of the Labor Code, you must forth euILOINGa with comply with such provisions or this permit shall baCONNECTION CHARGE P¢8 deemed revoked CONTRACTOR LICENSED CONTRACTORS DECLARATION ADDRIBSCIfi REIMBURSEMENT FEE I hereby affirm that 1 em licensed under provisions of Chapter .Tw1.T woSou NAP k;�ZO eY 9 (commencing with Section 7000) of Division 3 of the Bust .ITY TEL x .'K/ w ness and Professions Code and my license Is In full force and STATE Ie ee V — effect LICE .. NO CLA9a 66 P / NO DESCRI"IONicF WORK F66 ALIDATION Hou•.IS,waw Cow..cnwc To FINAL _ License Numh Lic Class PO.LIc•.waw DATE •a PTI.T ww wfP.D. PIT Ow Contracto I atC PIT.w.D/OR.....'.LD FINAL w A..N.CTINO To Is — ❑ FRrvwT. DIOALY. ow 1 am exempt from the licensing requirements as 1 am e I architect of a registered professional engineer We.. I. ADDITIONAL gi p gl ROAR TO W SME ..... acting d my professional capacity (Section 7051 Bus Ov.RaoSSPOOL G. PIT LL AIK...1 V/ meas and Professions Code) ALTER CESSPOOL DRYWZAIIANDL MANHOL. wvew we PwlR ow w.wNDOH Roe.. view OR o omwL.T ST.M Ge or Reg No Dete ` HOMEOWNER BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors OWNER'S Permit s License Law for the following reason (Section 7031 5, But AUTHORIZATION TOTAL FEE ness and Professions Code) "Av. w DATA A CONTRACT WITH THE K.D c ❑ TRACTOR TO CONN.cT TH.A.ov.O.•CMIDED � �wo Oweuwc 1, as owner of the property will do the work and the TO TH.P .LIC structure Is not intended or offered for sale (Section SIGNED THIS DAY OF ro 7044 Business and Professions Code) owx.w oe -9376.9A DwHaR•wO. CONSTRUCTION LF affirmconstruction AGENCY # S S e • l O I hereby that there Is a construction lending agency ADDwev for the performance of the work for which this permit Is 2 a 1 a O O issued (Sec 3097,Civ C) Lender Name .,. • 1 a 0 0 QX Lender's Address 0114-81 I certify That I have read this application and state that the above Information is correct 1 agree to comply with all County ordinances and State la Ws regulating Plumbing and Sewers and herpby aurthy[s a representatives of this CUnurposes to enter U pon (e abov�n do (operly for InspecyyySEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee pate