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HomeMy Public PortalAbout5219 AGNES AVE_Sewer_7/6/1983_connect addtl bldg to house 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 certified copy thereof (Sec. 3800, Lab C. CE 808(REV.8/61) APPLICATION FOR PERMIT Policy No. Company ©s ❑ 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 Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS This section need not be completed if the work involved b the UPPER ( p y LOCALITY MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or-less.) r TYPE OF CONNECTION NEAREST ) LENGTH FROM I certify that in the performance of the work for which this CROSS 5T. Y. CURB P.L. M.L.TO P.I. � permit is issued, I shall not employ any person in any manner 53. P.C.NO. so as to become subject to the Workers'Compensation Laws. O I p OWNER d' CO.IMP.NO.. !OB NO. U MAIL ell TRUNK PERMIT NO. ROAD PERMIT NO. C1 Date Applicant ADDRESS Is ID - �� "' AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. I DATE 0-- Exemption, you should become subject to the Workers' LEGAL s3 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 NO.OF BLDGS. PERMIT NO. I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE 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 CONNECTION CHARGE FEE License Number Lic.Class ADDRESS REIMBURSEMENT FEE Contractor Date CITY TEL.NO. DISTRICT NO. GROUP MAP PROCESSED BY / BK PG ❑ I am exempt under Sec. of the L.A.Co. STATE c NSE NO. CLASS yAdJ! Q Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL z , HOUSE SEWER CONNECTING TO DATE VALIDATION B. & P. Code for the following reason PUBLIC SEWER r SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM SignatureCONNECT ADDITIONAL BLDG.OR / 01111.OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,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). OWNERS Permit $ ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE a,3 4 3. 1 A licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONIRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. �t O 0 O ° 1 0 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 c ° O2 1.5 0 c=,• ADDRESS Lender's Name 0706-83 Lender's Address I certify that I have read this application 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 above-mentioned property for inspection purposes. Signat r of Permittee to SEE REVERSE FOR EXPLANATORY LANGUAGE