HomeMy Public PortalAbout4831 AGNES AVE_Sewer_9/29/1980_ WORKERS COMPENSATION DECLARATION D
CE 808 (2 80) APPLICATION FOR P E R M I T
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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: