HomeMy Public PortalAbout4829 AGNES AVE_Sewer_7/29/1980_ WORKERS'COMPENSATION DECLARATION CE 808(2 80) APPLICATION FOR PERMIT
f
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
Insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No, 397
1 / Company
79 FOR APPLICANT TO FILL IN CONNECTION DATA
❑ Certified copy is hereby furnished
BUILDING 3y�� TATION / DEPTH
Certified copy Is filed with the county building Ins tion ADDRESS G �JGr � c7 �J
department ` LOCALITY G + / PPER
Date1Z_I—Po Applicant �" ��-/ - - s' MANX OLE REFERENC¢Zd /g `/
PP NEAREST TYPE OF CONNECT LENGTH F M WER
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST L� ztr.r,� Y CURB P L M L TOP J /
COMPENSATION INSURANCE PC NO
OWNER ! �/ / }�/� r/�// CO IMP NO JOB NO
MAIL �VS G / �70� / a
(This section need not be completed if the Work involved ADDRESS + O TRUNK PERMIT NO ROAD PERMIT NO
by the permit is for one hundred dollars ($100) Or less) 0
AFFIDAVIT WAIVEREM
WAIVER ASEENT RECORD INSTR NO DATE U
CITY 6 TEL NO —707r-5Z z
I certify that in the performance of the work for which this LEGAL O
permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO HwY OR sr WIDENING 0
so as to become subject to the Workers' Compensation Laws 7�3�� U
BLOCK TRACT J STATE ENCROACHMENT W
Date Applicant NO OF BLDGS PERMIT NO d
NOTICE TO APPLICANT If, after making this Certificate of SIZE of Lor Now ON LOT CAZ
Exemption, you should become subject to the Workers' USE OF _:51 / CHARGES
Compensation provisions of the Labor Code, you must forth BUILDINGS
with comply With SUCK provision Or this permit shall be CONTRACTO�p!iQ ' ��� /� CONNECTION CHARGE FEE
deemed revoked
LICENSED CONTRACTORS DECLARATION ADDRESS 1 1F REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO GROUP MAP PROCESSED BY
9 (commencing with Section 7000) of Division 3 of the Bust CITY TEL NoBK PG
ness and Professions Code, and my license Is in full force and STATE LIC 09 Q_/ L//�'
LICENSE NoZ CLASS /4--
effect of O` NO DESCRIPTION OF WORK FEE
G / '//� J HOUSE SEWER CONNECTING TO FINAL Q �C/j] VALIDATION
License Num erT_ Lic Class r1 / PUBLIC SEWER / DATE A"
�y q SEPTIC TANK SEEPAGE PIT OR
Contracto Date- / ���d' PITS AND/OR DRAINFIELD FINAL
HOUSE SEWER CONNECTING TO
F1BV
I am exempt from the licensing requirements as I am a PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting in my professional Capacity (Section 7051, Bus OVERFLOW SEEPAGE PIT DRAINFIELD
iness and Professions Code) EXTN CESSPOOL DRYWELL MANHOLE
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic or Reg No � 6� Date Z e d
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNERS Permit f ',
License Law for the following reason (Section 7031 5, Bust AUTHORIZATION TOTAL FEE I Ir
nese and Professions Code) I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
E]
TRACTOR O CONNECT THE ABOVE DESCRIBED E%ISTING DWELLING
I, as owner of the property, will do the work and the To THE PUBLITC SEWER
structure is not intended or offered for sale (Section SIGNED THIS DAY OF is O
7044, Business and Professions Code) OWNER`OR
OWNERS AGENT
CONSTRUCTION LENDING AGENCY 4 2 3 2 3 A
I hereby affirm that there is a construction lending agency ADDRESS
for the performance of the work for which this permit is # B B B B 1 p
issued(Sec 3097,Civ C)
Lender's Name ` 2'0 B 1 8 00
Lender's Address
. . . 1800
I certify that I have read this application and state that the
above information is correct I agree to comply with all County 0929-80
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above mention p e t inspection purposes
2� 1dr0 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat of Xtax-40or Date