HomeMy Public PortalAbout4949 AGNES AVE_Sewer_4/5/1957 „— WQRKERS COMPENSATION DECLARATION 92 0002 DPW 3/87
i hereby affirm that I have a certificate of consent to self
D
E 808
irTsure ora certificate of Workers Compensation Insurance or C
a certified copy thereof (Sec 3800 Lab C ) CE 808 APPLICATION FOR PERMIT
Policy No Company Os
❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE LUPPER
OWER
permit is for one hundred dollars ($100)_or less )
I Certify that In the performance Of the work for Which this CROSSSST TYPE OF CONNECTION MLLENGTH
Y CURB P L M L TOOPPL L
permit is issued I shall not employ any person in+any manner '�^
1 so as to become subject to the rkers Compensation Laws OWNER �`J(J/f/r//!fL' � co IMP No PC
No '
Dat.al� Applicant ` # ADDRESS 9y P1 (N TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT I ter making this Certificate of CITY TEL NO AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
Exemption you should ecome subject to the Workers
LEGAL
Compensation provisions of the Labor code you must forthwith DESCRIPTION LOT NO HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed
revoked BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO OF BLDG$ PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE OF
9 (commencing with Section 7000) of Division 3 of the Busi BUILDINGS CHARGES
ness and Professions Code and my license is in full force and
effect CONTRACTOR Aln CONNECTION CHARGE FEE
License Number LIc Class ADDRESS REIMBURSEMENT FEE 0
Contractor + Date CITY TEL NO DISTRICT NO GROUP MAP PROCESSED BY 0
TATE BK PG Z
El am exempt under Sec of the L A Co 5 ENSE NO LIC BK
' O
Plumbing Code and/or Sec of the No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO DF/i �—� VALIDA N W
B & P Code for the following reason PUBLIC SEWER G�
SEPTIC TANK SEEPAGE PIT OR FI L Z
PITS AND/OR DRAINFIELD
Data HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG OR
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER , -2 8 9 8,8 A
I hereby affirm that I am exempt from the Contractors License OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE # o e oeo O
Low for the following reason (Secton 7031 5 Buisness and Pro 4 ALTER REPAIR OR ABANDONH SE �L
fessions Code) SEWER OR DISPOSAL SYSTEM 6-
I as owner of the property or my employees with wages as L J
their sole compensation will do the work and the structure m e o 2 1 J O x
is not intended or offered for sale (Section 7044 Business
and Professions Code) OWNER S Permit y
❑ 1 as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE Q 2'19-88
licensed COn1raC10fS 10 construct the project (Section 7044 1HAVE 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 j
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit is OWNER OR
issued (Sec 3097 Civ C ) OWNERS AGENT
ADDRESS
Lender s Name
Lender s Address
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 jaws regulating Plumbing and Sewers
and ereby authorize representattves of this County to enter
on T above mentioned property for inspection purposes
1
�Sgna�t.,eof Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
i