HomeMy Public PortalAbout5746 AGNES AVE_Sewer_9/27/1991_house sewer connection to public sewer WORKERS'COMPE+TION DECLARATION
1 hereby affirm that I have a certificate of consent to self 92-0002 DPW 3/87
insyre,.or a'tertificate of Workers' Compensation Insurance, or 08 D
CE 8
a certified copy thereof (Sec. 3800, Lab C. oB APPLICATION FOR PERMIT
Policy No. Company ®s
F-1Certifiedcopy 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' fNEARE'TLDING STATION �--� �O DEPTH
COMPENSATION INSURANCE RESS ((/J
(This section need not be completed if the work involved by the MANHOLE REFERENCE /.�. UPPER
permit is for one hundred dollars ($100)or less.) ALITY - LOWER
TYPE OF CON TION LENGTH FROM1 certify that in the performance of the work for which this SS ST. Y. P.L, M.I.TO P.I.
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. P. B NO.
I P - OWNER (}��� i CO.IMP.NO. JOB NO.
MAIL
Date Applicant ADDRESS TRUNK PERMIT NO, ROAD PERMIT NO.
NOTICE TO APPLICANT: If, after making this Certificate of CITY ` NO ^
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.
�n SIZE OF LOT L� { 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- BUILDINGSCHARGES
ness and Professions Code, and my license is in full force and �I" F
effect. CONTRACTOR '/ _ CONNECTION CHARGE FEE
License Number Lic.ClassADDRESS �C REIMBURSEMENT FEE a
G,
Contractor DateDISTRICT NO. GROUP MAP PROCESSED BY L)
-
CITY EL.NO. VIRI
BK PG '�'�_�++_�-�s�
❑ I am exempt under Sec. of the L.A.Co. STATE LICENSE NO. C ASS O
t=
CJ
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE 'FINAL VALIDATION W
HOUSE SEWER CONNECTING TO DATE
B. 8 P. Code for the following reason PUBLIC SEWER 0.SEPTIC TANK,SEEPAGE PIT OR FINAL v �_
PITS AND/OR DRAINFIELD
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR LU,
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ® r =
OVERFLOW SEEPAGE PIT,DRAINFIELD A*,t•
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, BUlsness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM --- `i'a,..•.:
❑ I, as owner of the property,or my employees with wages as T!P-11
their sole compensation, will do the work and the structure s•.= _
is not intended or offered for sale (Section 7044, Business 4 a X35
and Professions Code). OWNER'S Permit $Lz Ir" 0 '�`
` :,
I, as owner of the property, am exclusively contracting with AUTHORIZATION r TOTAL FEE Iq 6
licensed contractors to construct the project Section 7044, _•!-ir:i
P I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY
I herebyaffirm that there is a construction lending agency SIGNED THIS DAY OF 19_
9 g Y
for the performance of the work for which this permit is OWNER OR L`OWNERS AGENT ,
issued (Sec. 3097, Civ. C.). ADDRESS
Lender's Name
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
on a above-me n property for inspecti purposes.
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Si oture of Per ee Date SEE REVERSE FOR EXPLANATORY LANGUAGE