HomeMy Public PortalAbout4847 3/8, 4853 AGNES AVE_Sewer_1/17/1990_ r
WORKERS COMPENSATION DECLARATION j
I hereby affirm that I have a certificate of consent to self
Insure or a certificate of Workers Compensation Insurance or 76A642D ,
a cert,WP (Sec 3800 820002 DPW 8/88 APPLICATION FOR PERMIT
Policy Compony �'4'U - i SEWER - SEWAGE DISPOSAL
❑ Certified copy is hereby furnished - t
Certified copy ,s filed with th my building inspection COUNTY OF LOS ANGELES AND SAFETY i
department IBUILDING
LI
Date 0 ppl,cant '— FOR APPLICFTTO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ADDRESS STATION DEPTH
This section need not be completed,f the work involved b the UPPER
( p y MANHOLE REFERENCE LOWER
permit ,s for one hundred dollars($100)or less )
LOCALITY
I certify that In the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM
CROSS ST Y J CURB P L TO P L a.
permit ,s issued I shall not employ any person ,n any manner
so as to become subject to the Workers Compensation Laws OWNER CO IMP NOL
0
MAIL
Dote—Applicant ADDRESS -za ( TRUNK PERMIT NO ROAD PERMIT NO
,
RECORD INSTR NO DATE
EASEMENT
11115-OL,
_ I
NOTICE TO APPLICANT If after making this Certificate of CITY _— �l/(,./-0/. TEL � AFFIDAVIT WAIVER
Exemption you should become subject to the Workers LEGAL I {
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 It ,
revoked BLOCK TRACT STATE ENCROACHMENT f
LICENSED CONTRACTORS DECLARATION -' NO OF BLDGS PERMIT NO t
I hereby affirm that 1 am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE OF
9 (commencing with Section 7000) of Division 3 of the Bus, BUILDINGS , CHARGES
ness and Professions Code and my license ,s ,n full force and
effect �f CONTRACTO CONNECTION CHARGE FEE r c
License Nu/mCb�.4��Q� / L. Class ADDRESS REIMBURSEMENT FEE
Contractok, �� Date A—ItAFQ DISTRICT NO GR MAP PROCESSE BY
CITY TEL BK PG
❑ I am exempt under Sec of the L A Co LICENSE NO cCASSr/'U O
Plumbing Code and/or Sec of the NO b9SCRIPTION OF WORK FEE FINAL �� JJ U
/ PBL C SEWER CONNECTING TO ¢1 DATE JVALIDATI N
B 8 P Code for the following reason SEPTIC TANK SEEPAGE PIT OR �J FINAL / �� /1 O
w PITS AND/OR DRAINFIELD J T IU
Date HOUSE SEWER CONNECTING TO BY 1,
PRIVATE DISPOSAL SYSTEM +
Signature CONNECT ADDITIONAL BLDG OR CL® Tri
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER z
I hereby affirm that I am exempt from the Contractor s License OVERFLOW SEEPAGE PIT DRAINFIELDEXTN CESSPOOL DRYWELL MANHOLE iiry
Law for the following reason (Section 7031 5 Bu,sness and Pro ALTER REPAIR OR ABANDON HOUSE 1V
fess,ons Code) SEWER OR DISPOSAL SYSTEM ACICI aT
❑ I as owner of the property or my employees with wages ass i
their sole compensation will do the work and the structure 3007 34■5[I
,s not intended or offered for sale (Section 7044 Business
and Professions Code) OWNER'S I Permit $ I 00 1 ITEM]
❑ I as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE- AATOTAL �.®��
licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A�CONTRACT WITH THE HMEREIN NAMED NTR CTOR TO �+�/
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER 'CHE4r7 34.910
CONSTRUCTION LENDING AGENCY r r
I hereby affirm that there ,s a construction lending agency SIGNED THIS DAY OF + 19_ ® CHANGE oOcl-
for the performance of the work for which this permit ,s OWNER OR
Issued(Sec 3097 Civ C ) OWNERS AGENT
Lender s Name ADDRESS ° MOOi]-=I 1/17/90
Lender s Address $ 1 AM110-n
I certify that I have read this application and state that the '
above inform on Is correct I agree to comply with all County
o dF
St Ws regulating Plumbing and Sewers
anor,ze pr entat,ves of this County to enter
upmerit ne property for inspection purposes -
( - - ?J
erm,ttee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
4