HomeMy Public PortalAbout4859 AGNES AVE_Sewer_1/17/1990_house sewer connecting to public sewer WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76A642D
a certifiedco r ec. 38 sz-000zDPW siae
Policy N Ompay°° C. � APPLICATION FOR PERMIT
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
R—C�tified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
' rpar�nt' �J
Date kdpplicant FOR APPLICAN3fO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS STATION DEPTH
(This section need not be completed if the work involved by the MANHOLE REFERENCENEARE
! 7 UPPE
permit is for one hundred dollars ($100)or less.) LOCALITY
I certify that In the performance of the Work for which this CROSSSS7 TYPE OF CONNECTION LENGTH FROM
Y. CURB P.L. .L.TO P.L.
permit is issued, I shall not employ any person in any manner
P.C.NO
so as to become subject to the Workers'Compensation.Laws. � OWNER � CO.IMP.NO.MAIL TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
is Certificate O
NOTICE TO APPLICANT: If, after makingthis CIT e TEL.NO �
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
- .
Exemption, you should become subject to the Workers' LEG L
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. BLOCK TRACT STATE ENCROACHMENT NO.OF BLDGS. PERMIT NO.
LICENSED CONTRACTORS DECLARATION 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
ness and Professions Code, and my license is in full force and
effect. �'//// CONTRACTOR -r CONNECTION CHARGE FEE
License Number! C IOSs r/ ADDRESS REIMBURSEMENT FEE
Contractor / Date ~3/ o DISTRICT NO. GR MAP PROLE SED BV
CITY TEL.NO. �/ BK PG >
❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. rrrCLASS l� � CL
Plumbing Code and/or Sec. of the N9. DESCRIPTION OF WORK FEE FINAL U
HOUSE SEWER CONNECTING TO DATE VA ATI N
B. & P. Code for the following reason PUBLIC SEWER O
SEPTIC TANK,SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY 0.
PRIVATE DISPOSAL SYSTEM /
Ld
Signature CONNECT ADDITIONAL BLDG.OR ® I CL
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD z
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE PPV
i{1
Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE bV
fessions Code): SEWER OR DISPOSAL SYSTEM !3.
4
❑ I, AGti'0
as owner of the property,or my employees with wages as �� t:
their sole compensation, will do the work and the structure ,3.397 34.50
is not intended-or offered for sale (Section 7044, Business Permit $ (� 1 ITEMS
and Professions Code). OWNER'S
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE I TOTAL 34 o 50
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CHECK 3!.50
CONSTRUCTION LENDING AGENCY r�f!`Ap�/'� R ttV
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ ® C•HANIGE .00
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT
Lender's Name ADDRESS 0000_0001 AM
1 17/90
Lender's Address 08322L2y W 1 AM1I'D55
1 certify that I have read this application and state that the
above infor tion is correct. I agree to comply with all County
ordinonc nd S ws re ulating Plumbing and Sewers,
and h orize pre tatives Of this County to enter
upon ab ve-me one roperty for inspection purposes.
/'/7J
Signa tur o eIMittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE