HomeMy Public PortalAbout5729 AGNES AVE_Sewer__ WORKERS COMPENSATION DECLARATION o
I hereby affirm that I have a certificate of consent to self
Insure or a certificate of Workers Compensation Insurance or 7aAaazo
o certified �ppy,fhgrg CE American Ins �SBoe(REV 8/811 APPLICATION FOR PERMIT
Policy No WWII::WW j y ��y ww
❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
® Certified copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
Date epc�rtrr�eyit 83 Applicant Economy �'lumbing FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING STATION DEPTH
COMPENSATION INSURANCE ADDRESS 5729 Agnes Ave/
UPPER
(This section need not be completed if the work Involved by thep LOWER
LOCALITY Temple ity MANHOLE REFERENCE
permit Is for one hundred dollars ($lOO)Or IQSS ) NEAREST ijive s TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSS ST Y CURB P L ML TO P L d
permit is Issued I shall not employ any person in any manner Jaber P c No
so as to become subject to the Workers Compensation Laws OWNER g CO IMP NO JOB NO 0
MAIL
Date Applicant ADDRESS
5729 Agnes TRUNK PERMIT NO ROAD PERMIT NO
-
Temple Cit AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE O
NOTICE TO APPLICANT If after making this Certificate of CITY P yTEL No 9 V
Exemption you should become subject to the Workers LEGAL
LAA
Compensation provisions of the Labor code you must forthwith DESCRIPTION 3 LOT NO HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed H
revoked BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION No of PERMIT NO
LOT
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 COnOmy Um Ing
rt CONNECTION CHARGE FEE
effect CONTRACTOR
License Number 271 LIC Class- 36 ADDRESS 15 E Walnut St REIMBURSEMENT FEE
44-9 1910
COnfraClOfEconomy Plbg Date 10-26-83 CITY Pasadena TEL NO DISTRICT NO GROUP MAP PROCESSED BY
BK PG
El am exempt under Sec of the L A Co SCENSE NO 247190 TATE LIC
C36
Plumbing Code and/or Sec of the
NO DESCRIPTION OF WORK FEE Q +++yyy ����_rrrr
HOUSE SEWER CONNECTING TO DA EL �� / VALIDATION
//
B 8 P Code for the following reason PUBLIC SEWER l W / 4 �]
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL
Date BY
HOUSE SEWER CONNECTING TO "r
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG OR
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER CC ,
OVERFLOW SEEPAGE PIT DRAINFIELD `o 2 6 3 6,0 A
I hereby affirm that I am exempt from the Contractors License EXTN CESSPOOL DRYWELL MANHOLE
Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
fessions Code) l0 0 0 0 1 0
❑ I as owner of the property or my employees with wages as ` 2 0 0 2 1 5 0
their sole compensation will do the work and the structure
Is not intended or offered for sale (Section 7044 Business o o e 2 1 5 0=
and Professions Code) OWNER S Permit $ 10 50
❑ I as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE 154 50 1 026-83
licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED TRACTOR TO
Business and Professions Code) 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 l�
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 jaws regulating Plumbing and Sewers
and herebauthorize represents es of this County to enter
upon? a ov mention pro rty for spection purposes i
Signature of Permittee Alate SEE REVERSE FOR EXPLANATORY LANGUAGE