HomeMy Public PortalAbout4857 AGNES AVE_Sewer_1/17/1990_house sewer connection to public sewer WORKERS COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -
insure or a certificate of Workers CompenLqlion Jnsuronce or 76A642D
a car (Sec 3800 La 920002 DPW 6/811 APPLICATION FOR PERMIT
lic Company
❑ SEWER - SEWAGE DISPOSAL R
Certified copy is hereby furnished 4 � i
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
ba}��apart nt �J
Applicant FOR APPLICAN TO FILL IN CONNECTION DATA
TT CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE nooaESS STATION DEPTH
(This section need not be completed if the work involved by the G- MANHOLE REFERENCE UPPER
' permit is for one hundred dollars ($100)or less ) LOCALITY d
I certify that in the performance of the Work for which this NEAREST TYPE OF CONNECT N LENGTH FROM
CROSS ST Y CURB P L TO P L
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation laws OWNER , CO IMP NO c los
MAIL TRUNK PERMIT NO ROAD PERMIT NO
Date Applicont ADDRESS
NOTICE TO APPLICANT If after making this Certificate Of i CITY TEL NO AFFIDAVIT i WAIVER EASEMENT RECORD INSTR NO DATE i
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 I
revoked BLOCK TRACT STATE ENCROACHMENT s
LICENSED CONTRACTORS DECLARATION NO OF BLDGS 4 PERMIT NO 1
SIZE OF LOT NOW ON LOT +
I hereby affirm that I am licensed under provisions of Chapter USE OF
9 (commencing with Section 7000) of Division 3 of the Busi BUILDINGS CHARGES -A
ness and Professions Code and my license is in full force and
effect A CONTRACTO CONNECTION CHARGE FEE
License Number C
CIas �S ADDRESS REIMBURSEMENT FEE t
Contractor � CITY TEL DISTRICT NO G MAP I PROCE ED BY
STATE /��J� BK PG }
❑ I am exempt under Sec of the L A Co
LICENSE NO LIC
J1 / O
Plumbing Code and/or Sec of the SCRI I F RK FEE FINAL U
HOUSE SEWER CONNECTING TO 0 DATEd)JW �0 V LIDAT ON 0
B 8 P Code for the following reason PUBLIC SEWER (/ O
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO E BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG OR
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER ®� _ Z_
I hereby affirm that I am exempt from the Contractors License OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE 10
Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE
fessions Code) SEWER OR DISPOSAL SYSTEM Af f T AL
El as owner of the property or my employees with wages as 1;i4�i.7 �4s
their sole compensation will do the work and the structure
is not intended or offered for sale (Section 7044 Business Permit S 1 ITEMS
and Professions Code) OWNER'S
❑ I as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE TOTAL 34.50
licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO + `K �4�
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER `�I CK
CONSTRUCTION LENDING AGENCY ® (HANGiE .00
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit is OWNER OR
issued (Sec 3097 Civ OWNERS AGENT C ) 0000-0001 1f 17�9tI
Lender s Name ADDRESS
Lender s Addre 8321 1 AM11.59
I certify tho have read this application and state that the "
above inf do orrect I agree to comply with all County
ordinanc Stat laws regulating Plumbing and Sewers
and he authors representatives of this County to enter
upon t ove ntio ed property for inspection purposes
t-/7- 74>
Ssgnotu f Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE