HomeMy Public PortalAbout5733 AGNES AVE_Sewer__ 4 WORKERS COMPENSATION DECLARATION
I hereby Affirm that I hove a certitioate of consent 4o self
Insure br a certificate of Workers Compensation Insurance or 76A642D
a certified Sopy thereof(Sec 3800 Lab C ) 920002 DPW 6/88 APPLICATION FOR PERMIT
Policy No Company
❑ 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
COMPENSATION INSURANCE ADDRESS s r r Ls - STATION DEPTH
(This section need not be completed if the work involved by the LOCALITY 7e_..+ / �,/v MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less ) LENGTH FROM
I certify that in the performance of the work for which this cCRONEASSSTYPE OF CONNECTION T
IVf OD/L V CURB PL Ml TOPL
permit is issued I shall not employ any person in any manner � PC No
so as to become subject to the Workers Compensation Laws OWNER C L - CO IMP NO JOB NO i
MAIL
Date Applicant
ADDRESS C G�S1- - -s TRUNK PERMIT NO ROAD PERMIT NO
` AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
NOTICE TO APPLICANT If after making this Certificate of CITY T t— TEL NO ��V S'%
Exemption you should become subject to the Workers LEGAL
Compensation provisions of the Labor code you must forthwith DESCRIPTION LOT No
comply with such provisions or this permit shall be deemed HWY OR ST WIDENING
revoked BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NOSIZE 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 Busl 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
4
Contractor —Date DISTRICT NO GROUP MAP PROCESSED BY
CITY TEL NO
❑ 1 am exempt under Sec of the L A CoSTATE LIC
(J�� BK PG 1 y nCL
p LICENSE NO CLASS 51 1 /� + �{V�`�' 0
Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL V O
HOUSE SEWER CONNECTING TO DATE VALIDATION
B 8 P Code for the following reason PUBLIC SEWER 0
SEPTIC TANK SEEPAGE PIT OR FINAL
PITS AND/OR DRAINFIELD I
Date BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG OR
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER G NFIELD Z_
I hereby affirm that I am exempt from the Contractors License EOXTNFLCESS SEEPAGE
DRIYWDLRAIMANHOLE
Low for the following reason (Secton 7031 5 Buisness and Pro qooL. ALTER REPAIR OR ABANDON HOUSE
fessions Code) SEWER OR DISPOSk SYSTEM
❑ I as owner of the property or my employees with wages as
their sole compensation will do the work and the Structure 10
is not intended or offered for sale (Section 7044 Business Oj�T
and Professions Code) OWNERSiPermit $ _ ,
�I as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE It I MM M7 21.!0
licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO T7ChtL'
Business and Professions Code) • CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER 1 ITEM
EM
CONSTRUCTION LENDING AGENCY ZS (�`'tTuTAL 21 .50
I hereby affirm that there is a construction lending agency
SIGNED THIS Y OF 19
for the performance of the work for which this permit Is OWNER OR ��� + ��/ 21. 1
Issued (Sec 3097 Civ C ) OWNERS AGENT L-�i
Lender s Name ADDRESS CK*E X00
Lender s Address
I certify that I have read this application and state that the 00OD-0001 10/25/89
above information is correct I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers 6392 1 AM 8:49
and hereb Uthorize representatives of this County to enter
up the o e mentioned property for inspection purposes
Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE