HomeMy Public PortalAbout5806 AGNES AVE_Sewer__ r-- ------- -- -- — --- -- ---- — ---- -- --- ---- —---- ---- -
I RKERS' COMPENSATION DECLARATION
j I here., ;m that I have a certificate of consent to self E
i
j insure, or`c,<_ertificote of Workers' Compensation Insurance, or 76A642D �1
a certified copy thereof (Sec. 3800, Lab C.) CE 60B(REV.1/831 APPLICATION FOR PERMIT
Policy No. Company
❑
SEWER - SEWAGE DISPOSAL
Certified copy is hereby furnished. II
❑ Certified copy is filed with the county building inspection { COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
j Date Applicant i FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING d
i COMPENSATION INSURANCE ADDRESS f �y y -+2 ' ! $TAiION DEPTH
1 (This section need not be completed if the work involved by theMANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCAUTv i I LOWER
that in the performance of the work for'which this NEAREST TYPE OF CONNECTION LENGTH FROM
I certify i y p CROS$ST. � � N G' V. CURB P.L. M.L.TO P.I.
permit is issued, I shall not employ any person in any manner
I so as to become subject to the Workers'Com ensation Las. OWNER A4p
. Aq
Dote�3 Applicant ADDRESS .r P.C. No.
i' +" CO.IMP.NO. JOB NO.
MAIL
P INS,
0,(-, j N�
a TRUNK PERMIT NO. ROAD PERMIT NO.
��
NOTICE TO APPLICANT: If, offer mak th.s Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR..NO, DATE
Exemption, you should become su ' ct t the Workers' aTv 1 .,, TEL.NO. �d-
LEGAL
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 I TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION SI • NONO.OF BLDGS' PERMIT NO.
�% ,
I hereby'offirm that I am licensed under provisions of Chapter ZE Of LOT W ON COT
of . "
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS 1— —J 416 CHARGES
i ness and Professions Code, and my license is in full force and
effect. CONTRACTOR
CONNECTION CHARGE FEE
License Number {Ir 1(� Lic. Class �ry ADDRESS _ VR
Controctor ��Date-'LJ" !� / J ROUP MAP PROCESSED BYCITV �� TEL.NO. gK PG
❑ I am exempt under Sec. of the L.A.Co. ucENSE No. ciA550 ONO. DESCRIPTION OF WORK FEEPlumbing Code and/0r Sec. ofthe VALIDATION
•HOUSE SEWER CONNECTING TO i B. 8 P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO /pi/J 0 9 3 5 A
PRIVATE DISPOSAL SYSTEM N C
Signature CONNECT,ADDITIONAL BLDG.OR # 0 0 0 0 1 0
OWNER-BUILDER DECLARATION WORK TOIHOUSE SEWER I
OVERFLOW SEEPAGE PIT,DRAINFIELD i
j I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL.MANHOLE ► 0 0 1,5 O
Law for the following reason (Sectors 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
' fessions Cade): SEWER OR DISPOSAL SYSTEM f 0 o O
21, 50x :
❑ I,as owner of the property, or my employees with wages as
their sole compensation, will do the work and the structure i (119-84
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit S
❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed contractors to construct the project (Section 7044, 1 HAVE AT THISIDATE 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 hereby affirm that there is a construction lending agency SIGNED THIS I C DAY OF 19
I for the performance of the work for which this permit is
OWNERS OWNER OAGENT
i issued (Sec. 3097, Civ. C.). /.
ADDRESS
1 Lender's Name
• j -
' 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.
Si6natureyPermItfee ,� Date SEE REVERSE FOR EXPLANATORY LANGUAGE