The URL can be used to link to this page

Home My Public Portal About4831 AGNES AVE_Sewer_9/29/1980 WORKERS COMPENSATION DECLARATION D CE 808 (2 80) APPLICATION FOR P E R M I T (:� j CE 808 I hereby affirm that I have a certificate of consent to self SEWER SEWAGE DISPOSAL insure or a certificate of Workers Compensation In-urance or a certified copy thereof(Sec 3800 �Cb C)� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.�rq�Company "T� l-ft�- ?`I FOR APPLICANT TO FILL IN CONNECTION DATA El Certified copy is hereby furnished [BAA ILDING STATION DEPTH71 Certified copy is filed with the county building inspection DRESS e/� VV UPPERartment CALITYMANHOLE REFERENCE _ OWER Date� —f�✓ Applicant �� "�'�� AREST TYPE OF CONNECTION LENGTH FCERTIFICATE OF EXEMPTION FROM WORKERS oss sT G>GjZ�s r CURB P L M L To P VCOMPENSATION INSURANCE P C NoCO ,MP NO JOB NOMAIL (This section need not be com leted if the work involved DRESS a PQ� �s ,/��6 � TRUNK PERMIT NO ROAD PERMIT NO O by the permit is for one hundred dollars (p1OO) OI less) /� / � �� AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE U CITY C>/ /V` TEL NO I certify that in the performance of the work for which this LEGAL permit is issued I shall not employ any person in any manner DESCRIPTION LOT No HWY OR ST WIDENING so as to become subject to the Workers Compensation Laws V BLOCK TRACT STATE ENCROACHMENT W Date Applicant NO OF BLDGS PERMIT NO iZ SIZE OF LOT NOW ON LOT N NOTICE. TO APPLICANT If after making this Certificate of 2 Exemption you should become subject to the Workers E uSOF CHARGES BU,LDINGSs C Compensation provisions of the Labor Code you must forth with comply with such provisions or this permit shall be CONTRACTOR�� l CONNECTION CHARGE FEE deemed revoked REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I dm licensed under provisions of Chapter DISTRICT NO GROUP MAP PR OCE seD By 9 (commencing with Section 7000)of Division 3 of the Bus, CITY TEL NO SK PG ness and Professions Code and my license is in full force and STATE , LIC �� Q effect LICENSE N CLA (/ n `r/y� (�// 3 —/ NO DESCRIPTION OF WORK FEE FINAL o� ', (J T No DESCRIPTION SEWER CONNECTING TO /O �A, VALIDATION License Number Lic Class PUBLIC SEWER DATE a{./ ,/osa SEPTIC TANK SEEPAGE PIT OR Contractor Date �D PITS AND/OR DRAINFIELD FINA HOUSE SEWER CONNECTING TO JV ❑ PRIVATE DISPOSAL SYSTEM BY I am exempt from the licensing requirements as I am a l CON NECT ADDITIONAL BLDG OR licensed architect or a registered profes venal engineer WORK TO HOUSE SEWER acting in my professional capacity (Section 7051 Bus OVERFLOW SEEPAGE PIT DRAINFIELD mess and Professions Code) EXTN CESSPOOL DRYWELL MANHOLE ALTER REPAIR ORA NOON HOUSE SEWER OR DISPOSAL AK STEM Lic or Reg No Date HOME OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors OWNERS Permit S License Law for the following reason (Section 7031 5 Busi AUTHORIZATION TOTAL FEE ness and Professions Code) 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON OTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I as owner of the property will do the work and the TO THE PUBLIC SEWER — structure is not intended or offered for sale (Section SIGNED THIS 2�i DAY OF is 7044 Business and Professions Code) OWNER OR - 25 3 2 A OWNER CONSTRUCTION LENDING AGENCY ADDRESS I hereby affirm that there IS a construction lending agency # B B B B 1 0 for the performance of the work for which this permit is issued(Sec 3097 Civ C) 2 - - 18.00 Lender s Name • • BB1a00:E Lender s Address I certify that I have read this application and state that the 0929-80 above information is correct I agree to comply with all Courty ordinances and State laws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter upon the above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signet of Per ttee Date 1: