HomeMy Public PortalAbout4847 1/2, 4855 AGNES AVE_Sewer_1/17/1990 WORKERS COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
Insure or a certificate of Workers Compensation Insurance or 76A642D I 4
a certifi dcop r (Sec 3800 L 920002 DPW 6/88 APPLICATION FOR PERMIT ,
PolicyCompany t
❑ Certified copy Is hereby furnished ! SEWER - SEWAGE DISPOSAL
ertified copy is filed with the ounty building Inspection COUNTY OF LOS ANGELES 'i BUILDING AND SAFETY
eLIapart eni +
ate Applicant CAJ FOR APPLICANT TO FILL IN CONNECTION DATA
CER FICATE OF EXEMPTION FROM WORKERS; BUILDING 1C '
COMPENSATION INSURANCE ADDRESS 4 STATION DEPTH
(This section need not be completed If the work Involved by the + C� MANHOLE REFERENCE PPER
LOCALITY a"rr
permit is for one hundred dollars($100)or less ) LOWER
I certify that in the performance of the work for Which this CCROSS ST TYPE OF CON CTION LENGTH FROM `
Y CURB ,P TO P L
permit Is Issued I shall not employ any person In any manner P c
so as to become subject to the Workers Compensation Laws ONOMAIL CO IMP NO 3
Date Applicant , a ADDRESS ZI TRUNK PERMIT O ROAD PERMIT O
NOTICE TO APPLICANT If after making this Certificate of CITY - O-. TEL AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
W/
Exemption you should become subject to the Workers LEGAL
Compensation provisions of the Labor code you must forthwith DESCRIPTION LOT NO HWY QRST WIDENINP 1
comply with such provisions or this permit shall be deemed
revoked BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION No of BLDGS PERMIT No 1 ,
I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT Now ON Lor
USE OF
9 (commencing with Section 7000) of Division 3 of the Busl BUILDINGS z , CHARGES
ness and Professions Code and m license Is In full force and "
effect CONTRACTOR CONNECTION CHARGE FEE ti
License Number LIC C S REIMBURSEMENT FEE
U&Jy 7��+ ADDRESS
Contractor -Date v �,r� DISTRICT O rG MAP PROCESS BY
CITY TEL NO j� BK PG >-
❑ 1 am exempt under Sec / of the L A Co LICENSE NO STATE CLASS Y j O
Plumbing Code and/or Sec of the NO CFSCRIFPrIOWOF WORK FEE FINAL
OV
,
USE SEWER CONNECTING TO DATE A DATI N
B 8 P Code for the following reason PUBLIC SEWERSEPTIC TANK SEEPAGE PIT OR FINAL O~
PITS AND/OR DRAINFIELD V
Date OUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM WCLSignature CONNECT ADDITIONAL BLDG OR ® CL
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER ,INFIELD Z
I hereby off irm that I am exempt from the Contractor s License EXNFLCESS OW SPOOL DR EPAGE IYWE L MANHOLE
Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON OUSE 10
fessions Code) SEWER OR DISPOSAL SYSTEM
JL
❑ I as owner of the property or my employees with wages as ACCTA
their sole compensation will do the work and the Structure 337 °r
Is not intended or offered for sale (Section 7044 Business
and Professions Code) OWNERS I Permit $ 1 ITEMS
❑ I as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE
licensed contractors to construct the project (Section 7044 i 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO TnTAL 34.50
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CHECK 34.SLI
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency SIGNED THIS DAY OF 19_ ® Cu �-['G
A fT i9
for the performance of the work for which this permit Is OWNER At,tVuV
OWNERS AGENT i
Issued (Sec 3097 Civ C )
ADDRESS
Lender s Name 0000_0001 Al/1790
Lender s Address r 1 E319 1 1'111
I certify that I have read this application and state that the /11°s Il
above Infor tion is correct I agree to comply with all County
ordinanc n jaws regulating Plumbing and Sewers
and he than repr ntatives of this County to enter
up ove ntion roperty for Inspection purposes '
40
Slgnotur of Permittee Date F SEE REVERSE FOR EXPLANATORY LANGUAGE