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Home My Public Portal About5943 AGNES AVE_Sewer_6/26/1986_ ~ WORKERS COMPENSATION DECLARATION I hereK/ 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 eoe(REV B/B,) 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 5, q3 .� j S j_ STATION DEPTH COMPENSATION INSURANCE ADDRESS (This section need not be completed If the work Involved by the MANHOLE REFERENCE UPPER permit Is for one hundred dollars ($100)or less ) LOCALITY /�(� LOWER NEAREST �y TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS Sr TVA-0-S �� Y- CURB P L M L TOP L permit Is Issued I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws PC NO OWNER CO IMP NO JOB NO MAIL TRUNK PERMIT NO ROAD PERMIT NO Date Applicant ADDRESS NOTICE TO APPLICANT If after making this Certificate of CITY AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE LEGA Exemption you should become subject to the Workers L Q TEL NO .- Z L 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 ENCROACHME T LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT WO _ '1 1 I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT U"OF * c (� 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 (�(�Q��1. �� Q CONNECTION CHARGE FEE 7 d License Number � �3!2 LIC Class //� ADDRESS (&00 ('J, /OLS'l/+� �/��S .� REIMBURSEMENT FEE Q Contractor Ai7�L0� 690 ate (owl BW CITY �fJ TEL NO T'7'7'� DISTRICT NO GROUP MAP PROCESSED BY V STATE +� j BK PG z ❑ I am exempt under Sec of the L A Co LICENSE NO (i7-2 3 cLCass ✓1 / 0 NO DESCRIPTION OF WORK FEE U Plumbing Code and/or Sec of The FINAL N W VALIDATI a HOUSE SEWER CONNECTING TO DATE B 8 P Code for the following reason PUBLIC SEWER i + I H SEPTIC TANK SEEPAGE PIT OR FI PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO i PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR , OWNER BUIL DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT DRAINFIELD 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 fessions Code) SEWERPR DISPOS L SY TE ❑ I as owner of the property or my employees with wages as 4 4 AP I JTO 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 -44898A licensed contractors to construct the project Section 7044 P I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACT �} � O�O O O 5 4 Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWERCONSTRUCTION LENDING AGENCYI eit5400I hereby affirm that there Is a construction lending agency SIGNED THISDAY OF 1 for the performance of the work for which this permit Is OWNER OR 1 54,005 Issued (Sec 3097 Civ C ) OWNERS AGENT o 0 Lender s Name ADDRESS 0 626-86 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 author ze representatives of this County to enter upon t Ove ntioned property for Inspection purposes i Signature of Permitt Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS COMPENSATION DECLARATION d her+Qby'affirm that I have a certificate of consent to self irAwre or d certifkote of Workers Compensation Insurance 76A642D a certified copy thereof (Sec 3800 Lab C , <nce or CE 808(REV 1/97) APPLICATION FOR PERMIT Policy No Company ❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL Certified copy is filed withthe c y b d inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY a department Date-5-3(9-0 Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING COMPENSATION INSURANCE ADDRESS STATION DEPTH t (This section need not be completed if the work involved by the � MANHOLE REFERENCE OWER LOCALITY permit is for one hundred dollars ($100)or less ) NEARE ,/ A I certify that in the performance of the work for which this CROSSSST G� UA A TYPE OF CONNECTION LENGTH FROM Y CURB PL ML TOP L permit is issued I shall not employ any person in any manner _ so as to become subject to the Workers Compensation Laws I (+ P c NO Q OWNER )� �D V j J CO IMP NO JOB NO Date Applicant r." MAILRESS Ate f TRUNK PERMIT NO ROAD PERMIT NO / ) /v NOTICE TO APPLICANT If after making this Certificate of CITY 4 CT TEL NO AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE Exemption you should become subject to the Workers 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 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 Busi BUILDINGS CHARGES ness and ProfPssionS Code and my license is in full force and ) ' effect CONTRACTOR \JJr�/ smq ISI &/V 4r CONNECTION CHARGE FEE License Number M1,77-9Lic Class C ADDRESS .2 5a / REIMBURSEMENT FEE 9 kl n� Contractor 171— Date 5--30-00CITY O AIR p V�/J TEL NO s`7 r��f�/� �DI.STTRIICT NO GROUP MAP PR ESS D BY v BK PG LIC STATE � /J' C ASS Cr b "�Y �� l 09 O ❑ I am exempt under Sec of the L A Co LICENSE NO w Plumbing Code and/or Sec of the No DESCRIPTION OF WORK FEE FINAL V HOUSE SEWER NNECTI G T DATE PUBLIC SEWER /JE / W B 8 P Code for the following reason ld SEPTIC TANK SEEPAGE PIT OR Ilin z PITS AND/OR DRAINFIELD FIN I Date HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM '( Signature CONNECT ADDITIONAL BLDG OR , OWNER BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT DRAINFIELD 1 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 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 S s(' ❑ 1 as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE licensed Contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTORBusiness and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWERCONSTRUCTION LENDING AGENCY ►I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 1 for the performance of the work for which this permit is OWNER OR issued (Sec 3097 Civ C ) OWNERS AGENT Lender s Name ADDRESS 1 4 2 7 55 0 Lender s Address 0 o 0 2 7 5 0 5 I certify that I have read this application and state that the ° above information is correct I agree to comply with all County 0 530-86 ordinances and State laws regulating Plumbing and Sewers and here authors representatives of this County to enter upont e bov a coned property for inspection purposes ,_S--3 0 fC ignature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE