HomeMy Public PortalAbout6360 TEMPLE CITY BLVD_Sewer__ WORKERS COMPENSATION DECLARATION
I hereby affirm that I hove a certificate of consent to self W-0 DPW 31U
Insure, or a keaIficate of Workers'Compensation Insurance or rOAAKRD
a""'fedjT6b '$jy` D �°°' `LWC 'Ins. co, am APPLICATION FOR PERMIT
Policy No pony
❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
91 Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date«_Applicant Owen TRrn4 DTnmisino FOR APPLICANT TO FILL IN CONNECTION DATA
jb1Ara,CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING /.n
``-II COMPENSATION INSURANCE ADDRESS !to STATION DEPTH
(This section need not be completed If the work involved by the UPPER
LOC JTY M HOLE REFERENCE
permit is fa one hundred dollar ($100)ofthe
or leu ) LENGTH FROM
I certify that In the performance of the work for which this caoss ST TM��O� IT
ION Y CVRB P l ML TOPT.
permit is issued, 1 shall not employ any person In any manner PC rRo
so as to become subject to the Workers Compensation Laws OWNER �I CO wit NO JOB ND
N ryw,
Date Applicant
NAIL
-QJ rlturx EFRAIIT No ROAD PERMIT ND
NOTICE TO APPLICANT If, aftmaking this Certificate of Cin. TE
LNo AFFIDAVIT wArvER EASEMENT REcoRD INSiR No DATE
ft
Exemption, you should become subject to the Workers
LEGAL
c om comply
with
on such
provisions
of the Labor code, you moat forthwith DESCRIPTION LOT NO ,y MST WBOENING
comply with such provisions or this perms shall be deemed
revoked Blois TRACT STATE tivrnonowiENr
LICENSED CONTRACTORS DECLARATION ND OF NDGs PERMIT NO
SIZE OF LOT NOW ON LOT
Se
1 hereby affirm that 1 iunder provision of Chapter USE OF
9 (commencing with Sectionon 7 7000 0) of Damon 3 of the Bun- BUILDINGS CHARGES
neo and Professions Code and my license is in full force and
effect CONTRACTORRrog- cCINFccTroH cFLARGE HE
r
License Number 231 ?41 LH: Class ADDRESS 4265 N. BaldnueRFIMBURSEMEM FEE S
DISTRICT HO GROUP MAP PROCESSED BY 0
Contmctor Oven Rrna_ Date TEL N
J
CITY El Monte D 443-0078 PIG Z
El am exempt under Sec of the L A Co Ian No 231 741 XCI. C36-20-16 ��� _� Ex: l.�uh O
Plumbing Code and/or Sec ofthe ND DESCRIPTION OF WORK FEE FINAL O
HOUSE SEWER COBBEC 11 G TO DATE VALIDATION W
B 8 P Cade for the following reason PUBLIC SEWER N
LANK SEEPAGE PIT OR FINAL =
Dote PTS AND/OR DRAINFIELD BY
HOUSE SEWER COMECTING TO
AIVA
Signature CONNECT AODInONM BLDG OR ,
OWNER-BUILDER DECLARATION WM%TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor s License CIARRE �CES,SPPoa DRGE YWEEU. Ji I Im01E
Low for the following reason (Secton 7031 5 Buisneu and Pro- ALTER REPAIR OR ABANDON HOUSE 11�
fesslorn Code) SEWER OR DISPOSAL SYSTEM
aP,I_T1,.
❑ I their
owner of the property or my employees h wages - r
then t sole compensation will do the work and the structurere -,,3[17 6,:T !-
Is not intended or offered for sale (Section 7044, Business
and Professions Code) OWNER'S Permit S 1 STEM
❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE d3
licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH TIE HEREIN NAMED CONTRACTOR TO T6TAL 66 . 53
Business and Professions Code) CONNECT ME ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER C HE(K 66 j
CONSTRUCTION LENDING AGENCY {�
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF I9_ ► CHANGE
for the performance of the work for which this permit is OAWER OR
issued (Sec 3097, Cw C J OWI AGENT
Lenders Name ADDRESS _i( 7/-2
Lender's Address 1 ? 1 AM 7:17
1 certify that I have read this application and state that the
above Information Is correct I agree to comply with all County
ordinances and Sate Iowa regulating Plumbing arid Sewers
d ereby authorize representatives of this County to enter
u o the above-mentioned property for Inspection purposes
IF 56
g Lure of Fermin" Datb I SEE REVERSE FOR EXPLANATORY LANGUAGE