HomeMy Public PortalAbout4833, 4825 AGNES AVE_Sewer_9/29/1980_ WORKERS COMPENSATION DECLARATION D
CE 808(2 80) APPLICATION FOR PERMIT
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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 uranpp or
a certified copy thereof(Sec 3800 L COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No 13971 Company
79 FOR APPLICANT TO FILL IN CONNECTION DATA
Certified copy is hereby furnished
BUILDING ADDRESS o c !/® `� STATION DEPTH ��
ER
Certified copy is filed with the county building inspection
apartment LOCALITY MANHOLE REFERENCE /0;�5
L
Date1-2--1 Applicant i L^��^'�^-J NEAREST TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS cRoss sr p -,. v cuRe P L M L TO P L
COMPENSATION INSURANCE PC NO
OWNER Co IMP NO JOB NO MAIL }
(This section need not be com leted if the work Involved ADDRESS a
P �� E� � �.`� TRUNK PERMIT NO ROAD PERMIT NO O
by the permit is for one hundred dollars ($100) or less) +-� AFF DAV T WAVER EA EMENT RECORD N TR NO DATE U
CIT �j�B,� TEL NO Q�Z
I certify that in the performance of the work for which this LEGAL Cc
permit is Issued I shall not employ any person in any manner DESCRIPTION LOT NO / HWY OR ST WIDENING Q
so as to become subject to the Workers Compensation Laws �3 77 V
BLOCK TRACT STATE ENCROACHMENT W
Date Applicant NO OF BLDGS PERMIT NO CL
NOTICE TO APPLICANT If after making this Certificate of SIZE OF LOT Now ON LOT Z
Exemption you should become subject to the Workers USE of CHARGES
Compensation provisions of the Labor Code you must forth BUILDIro s ,
with comply with such provisions or this permit shall be CONTRALTO CONNECTION CHARGE FEE
deemed revoked
LICENSED CONTRACTORS DECLARATIONADDRE —s REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter D TR CT NO GROU MA R cE ED Y
9 (commencing with Section 7000)of Division 3 of the Busi CITY TEL NO B3 G
ness and Professions Code and my license is in full force and STATELiC GI 3
LICENSE NOG CLASS
effect
L /2 NO DESCRIPTION OF WOR FEE
? s~1'"r9'l /:/—/ / MOB
E EWE CONNECT NG TO FINAL DATE 1b -2--?)
VALIDATION
IC Class UB C
License NumbeREWER
E T C TANK EE AGE TOR A
T D AND/OR ORA NF E
Contractor erg Date "-��� BY
HOU E EWER CONNECT NG TO
❑ R VATE D O A Y TEM BY
I am exempt from the licensing requirements as I am a CONNECT ADD T DNA B OG OR
licensed architect or a registered profes conal engineer WORK TO HOU E EWER
acting in my professional capacity (Section 7051 Bus OV ERF OW EE AGE T ORA NF E D
mess and Professions Code) EXTN CE 00 ORYWE MAN O E
A TER RE A R OR ABANDON HOU E
EWER OR D O A Y TEM
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors OWNERS Permit S1 31
License Law for the following reason (Section 7031 5 Busl AUTHORIZATI1 NJ TOTAL FEE
ness and Professions Code) HAVE AT TH DATE A CONTRACT W TH THE HERE N NAMED CON
RACTOR TO CONNECT THE ABOVE DE CR BED EX T NO DWE NG
I as owner of the property will do the work and the To HE UB C EWER
structure is not intended or offered for sale (Section SIGNED THIS,92.9=.AY OF I
7044 Business and Professions Code) OWNER DAG 2 2 3 3 7 A
OWNER AG
CONSTRUCTION Ll NDING AGENCY ADDRE # o D o o 1 0
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 2 0 0 8 0
issued(Sec 3097 Civ C)
Lender s Name
o • s 1 a 0 0 3:
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
ordinanLes and State laws regulating Plumbing and Sewers
and hereby authori?e representatives of this County to enter
upon the above mentioned property for spectio purposes
' 00�2d SEE REVERSE FOR EXPLANATORY LANGUAGE
r Signatur f Permit� Date