HomeMy Public PortalAbout4851 AGNES AVE_Sewer_1/17/1990_ WORKERS COMPENSATION DECLARATION '
I hereby affirm that I have a certificate of consent to self e
Insure or a certificate of Workers Compansetion visurance or 76A642D `
a certefee copy ther (Sec 3800�gb C ) 920002 DPW 6/88 - APPLICATION FOR PERMIT
Policy N ompany .�e���
[:1Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
Certified copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
�DQde r en s LI
'e Applicant [_�''W' FOR APPLICANT TO FILL IN CONNECTION DATA "
C�E OF EXEMPTION FROM WORKERS BUILDING
ADDRESS N� STATION DEPTH
COMPENSATION INSURANCE i UPPER
(This section need not be completed of the work Involved by the LOCALMANHOLE REFERENCE
permit is for one hundred dollars($100)or less ) NEAREST
• ' LOWER
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that In the performance of the work for which this CROSS ST Y CURB P L ML TO P L y t
permit is issued I shall not employ any person in any manner c N
so as to become subject to the Workers Compensation laws OWNER CO IMP NO
NAIL TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant ADDRESS _ 4
AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
NOTICE TO APPLICANT If after making this Certificate of CITY QW/ TEL No 2
Exemption you should become 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 4 BLOCK TRACT STATE ENCROACHMENT +
LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NO
SIZE OF LOT NOW ON LOT t
I hereby affirm that I am licensed under provisions of Chapter use OF
9 (commencing with Section 7000) of Division 3 of the Buse BUILDINGS CHARGES
ness and Professions Code and my license is in full force and
effect CONTRACTOR CONNECTION CHARGE FEE
License NumberLIc C SADDRESS REIMBURSEMENT FEE
Contractor � f DISTRICT NO GR MAP sPROC� 1 N E D BY
CITU TEL NO BK PG
❑ I am exempt under Sec of the L A Co uc NSE NO ATE CLLASS (� t
Plumbing Code and/or Sec of the
NO 'DESCRIPTION FINAL TION OF WORK FEE U
�,�
HOUSE SEWER CONNECTING TO DATE VALIDATION
B 8 P Code for the following reason , PUBLIC SEWER O
SEPTIC TANK SEEPAGE PIT OR FINAL
Date PITS AND/OR DRAINFIELD
HOUSE SEWER CONNECTING TO BY W
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG OR 1:/1
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT DRAINFIELD z
I hereby affirm that I am exempt from the Contractors License EXTN CESSPOOL DRYWELL MANHOLE
Low for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE
fesSions Cade) SEWER OR DISPOSAL SYSTEM 10
❑ I as owner of the property or my employees with wages as
their sole compensation well do the work and the structure MCI A
is not Intended or offered for sale (Section 7044 Business / „
and Professions Code) OWNER S Permit $ 3 O a�x074■iii l
❑ I as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE 1 ITEMS
licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COWRACTOR TO
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER ' TTAiAL ,_
t o CJ0
CONSTRUCTION LENDING AGENCY .,
SIGNED THIS DAY OF 19_ ® CHEry
-� I hereby affirm that there is a construction lending agency i � '�S4■50
for the performance of the work for which this permit is OWNER OR M
p p �VAI
issued (Sec 3097 Civ C ) OWNERS AGENT CHANGE
ADDRESS
Lender s Name _
Lender s Address x]000-0001 1/17/90
1 certify that I have read this application and state that the
° above enf ateo rrect I agree to comply with all County .718 1 AM11a5*
ordinan tat law regulating Plumbing and Sewers 1
and h author ere se Motives of this County to enter
upon bove nteo d property for inspection purposes
[ -17_ .
Signal a of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
1