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HomeMy Public PortalAbout5112 AGNES AVE_Sewer_4/28/1982_house sewer connection to public sewer 1 I III WORKERS COWENSA'PION DECLARATION CE 808 (D2 80) / APPLICATION FO R IP E R M I T - i I hereby affirm that I have a-certificate of consent to self SEWER-SEWAGE DISPOSAL Insure or a certificate of Workers Compensation Insurance or a certified yo �t a Af(Sec 3800�ibae Fund 1 COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No `Y f3 GCompany ? 1 Certified copy Is hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA / ��� BUILDING STATION DEPTH 5112 N• Anes AV• ® Certified copy Is filed with the county building Inspection ADDRESS 7M department pe (� MANHOLE REFERENCE /<-,-- 1 LOCALITY Tem le (✓'lt /V V LOWER I Date Applicant NEAREST Y TYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS -Ross sT a Rosa Dr. CURB P L M L TO P L COMPENSATION INSURANCE Clarence Newlin CO IMP No J A� P C NO OWNER OB NO MAIL L E. Pamela $d. (This section need not be completed if the work involved ADDRESS o TRUNK PERMIT NO ROAD PERMIT NO O� } by the permit is for one hundred dollars ($100) Or less) 1 certify that in the performance of the work for which this LEGAL U permit is issued I shall not employ any person in any manner DESCRIPTION LOT NO HWY OR ST WIDENING Sv t7l� so as to become subject to the Workers Compensation Laws Q BLOCK TRACT STATE ENCROACHMENT Date Applicant NO OF BLDGS PERMIT NO V SIZE OF LOT NOW ON LOT w NOTICE TO APPLICANT If after making this Certificate of OF �. v tl Exemption you should become subject to the Workers BUILD NGS Res CHARGES Z Compensation provisions of the Labor Code you must forth with comply with suchUare DealSeWerSerVlCe CONNECTION CHARGE FEE p y provisions or this permit shall be CONTRALTO deemed revoked REIMBURSEMENT FEE LICENSEQ,CONTRACTORS DECLARATION ADDRESS 2 Maxson Rd. I hereby affi-m nat I am licensed under provisions of Chapter c73 z DISTRICT NO GROUP MAP PROCESSED BY 9 (commerc ig with Section 7000) of Division 3 of the Busi CITY El Monte pp TEL NO 444-2020 BK PG ness and Professions Code and my license Is in full force and STATELICENSE No 12UU7© cLLIcAss ri�- 2 �� 7� effect NO DESCRIPTION OF WORK FEE f28Q8+7 C (C /1.].r HOUSE SEWER CONNECTING TO FINAL � VALIDATION Llcen,e Number 12 +8/ 0 Li- Class v— •2 PUBLIC SEWER DATE 1�� //1 /}�( SEPTIC TANK SEEPAGE PIT OR Co�itractor 0 Date T/G �V� PITS AND/OR DRAINFIELD FINAL HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM e� I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG OR / licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting in my professional capacity (Section /051 Bus OVERFLOW SEEPAGE PIT DRAINFIELDf mess and Professions Code) E%TN CESSPOOL DRYWELL MANHOLE ALTER REPAIR OR ABANDON HOUSE O O YS 7 SEWER OR DISPOSAL SYSTEM Lic or Reg No Date HOME OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors OWNERS I Permit S ro License Law for the following reason (Section 7031 5 Busi AUTHORIZATION I TOTAL FEE tea- -6 ness and Professions Code) I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING El I as owner of the property will do the work and the TO THE PUBLIC SEWER ;-53807A structure Isnot intended or offered for sale (Section I SIGNED THIS DAY OF I9 7044 Business and Professions Code) ]OWNER OR #,* °YD D 1 0 OWNERS AGENT CONSTRUCTION Lb NDING AGENCY ADDRESS L�J °iO 2250 I hereby affirm that tnere Is a construction lending agency for the performance of the work for which this permit is w °'- 22505 issued(Sec 3097 Civ C) ff 0 4 2 8'-8 2 Lender s Name Lender s Address I Lertify that I have read this application and state that the above information is correct I agree to comply with all Courty ordinances and State laws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter upon the above mentiond pr perty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE c --Z f Signature o Permittee Date w/