HomeMy Public PortalAbout4926 AGNES AVE_Sewer_4/7/1986_connect additional bldg to house sewer WORKERS COMPENSATION DECLARATION i
I-26-bvcif•Irm that I have a certificate of consent to self
'Jfftu" P 1�
Insure or u certif1laM of Workers Compensation Insurance or 76A642D
a4tertified copy thereof (Sec 3800 Lab C ) CE808(REV 1/83) APPLICATION FOR PERMIT
Policy No Company ' '
El Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date 6Applicant } FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING �� /�F�
COMPENSATION INSURANCE ADDRESS V G i STAtION DEPTH
(This section need not be completed if the work Involved by theLocallry �� T MANHOLE REFERENCE UP RR
permit Is for one hundred dollars($100)or less )
NEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which ,this CROSS STY CURB P L MI. TOP I.
permit is Issued I shall not employ any person in any manner J r
so as to become subject to the Workers Compensation Laws t OWNER 4 - CPU y/C9 + CO IMP NO / JOB NO
MAIL��J �� (r TRUNK PERMIT NO ROAD PERMIT NO
DateZ1=;Applicant ADDRESS
NOTICE TO APPLICANT If 'after making this kertificate of CITY TEL
AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
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 BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION s NO OF BLDGS PERMIT NO
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 I BUILDINGS AZ CHARGES
ness and,ProfPssions Code and my license Is In full force and
effect CONTRACTOR CONNECTION CHARGE FEE
License Number LIC Class ADDRESS orREIMBURSEMENT FEE d
DISTRICT NO GROUP MAP PROCESSED BY O
Contractor Date y CITY TEL NO O f/ /� SK PG W/
❑ I am exempt under Sec of the L A Co LICENSE NO CLrd W
ASS ` oY K � t76,NO' I NO DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec of the FINAL
HOUSE SEWER CONNECTING TO DATE r �� VALIDAT N W
B 8 P Code for the following reason PUBLIC SEWER �
SEPTIC TANK SEEPAGE PIT OR FINAL N
PITS AND/OR DRAINFIELD Z
Date HOUSE SEWER CONNECTING TO BY �3dr�
r PRIVATE DISPOSAL SYSTEM -� CJ
yz�__Za
Signature CONNECT ADDITIONAL BLDG OR
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER 8
OVERFLOW SEEPAGE PIT DRAINFIELD t� O O L g
I hereby affirm that I am exempt from the Contractors License EXTN CESSPOOL DRYWELL MANHOLE L
Law for the following reason (Secton 7031 5 Bulsness and Pro ALTER REPAIR OR ABANDON HOUSE
fessions Code) SEWER OR DISPOSAL SYSTEM U 0 x 8
ER 1 as owner of the property or my employees with wages as
their sole compensation will do the work and the structure
Is not Intended or offered for sale (Section 7044 Business
and Professions Code) x 0' OWNERS I Permit $ 3_0
❑'I as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE
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) a CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
CONSTRUCTION LENDING AGENCY ,
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 C) OWNERS AGENT
ADDRESS
Lender s Name
Lender s Address I
I certify that I have read this 6pplication and state that the
above Information is correct I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon the alboye mentioned roperty for inspection purposes
$(0,
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE