HomeMy Public PortalAbout6317 AGNES AVE_Sewer_10/24/1994_ WORKERS' COMPENSATION DECLARATION �j
20-0051 DPW 6T89
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or 76A642D
a cer)fied copy thereof Sec. 38000,,LLa�jr„c I- k4 APPLICATION FOR PERMIT
mpon,Certified copy is hereby furnished. ] SEWER . S`EWAGE DISPOSAL
❑ Certified copy is filed with co my buil ection COUNTY OF LOS ANGELES BUILDING AND SAFETY
de/partcm�e�nntp
Date�lp-?-- /�Applicont 4 _ FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTIOI FROM WORKERS' BUILDING n �J �/� STATION G DEPTH
COMPENSATION INSURANCE- ADDRESS &a J / )V wes 9�� �f0
(This section need not be completed If the work involved by theMANHOLE REFERENCE
permit is for one hundred dollars ($100) or less.) LOCALITY L � LOWER
ILNEAREST TYPE OF CONNECTION LENGTH FROM
I certify that in the performance of the work for which this CROSSST. Y M L TO P L
permit is issued, 1 shall not employ any person in any manner LEGAL P c NO
so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO. CO IMP NO JOB NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date Applicant
NOTICE TO APPLICANT: If, after makingthis Certificate of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
MAP BOOK PAGE PARCEL
Exemption, you should become subject to the Workers' NO.OF BLDGS.
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed USE OF
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION A PERMIT
I hereby affirm that I am licensed under provisions of Chapter OWNER /J / B �J' 3 ��J-0
9 (commencing with Section 7000) of Division 3 of the Busi- MAILgDDREss �� �LP'IC/� �YQ !l/ I/ CHARGES
ness and Professions Code, and my' license is in full force and
effect. (� CITU e TEL.NO.Qj �- L�=.1- CONNECTION CHARGE FEE
License Number LIC.Class "�—T� REIMBURSEMENT FEE
//� CONTRACTOR 4'Z.r
.'Re�)((fZ W'T Vte , d' 1) Q g q DISTRICT NO GROUP MAP PROCESSED By
Cantract'br C7 /7� _ /�-1' ADDRESS J_T, 14 ?y a,�'}moi y�e S� y BK PG
❑ I am exempt under Sec. of the L.A. Co. CITY&
(,ffl 2.4 0
Plumbing Code and/or Sec. of the STATE ^ LIC. FINAL t i a 3 V
LICENSE NO. �j .,� CLASS�.-'' .� DATE 7/ Q V,:/�UDATION 9�^
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE -Z!�" ( --• �LE^}31=�.'1
HOUSE SEWER CONNECTING TO FINAL < '�+�}!�•
Date PUBLIC SEWER D BY 1 E t W
SEPTIC TANK SEEPAGE PIT OR -S i_;S�_ 10 0 = ��F
Signature
PITS AND OR DRAINFIEID
HOUSE SEWER CONNECTING TO
0 NER-BUILDER DECLARATIQ PRIVATE DlsaosAL sysTEM CHECt f'
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR s I '=�= T•_
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER _ ,y'{ Lr e1-
OVERFLOW SEEPAGE PIT DRAwFIELD
fessions Code): EXTN.CESSPOOL. DRYWELL,MANHOLE
I, as owner of the property, or my employees with wages as ALTER.REPAIR OR ABANDON HOUSESEWER OR DISPOSAL SYSTEM
their sole compensation, will do the work and the structure
is not intended or offered for sole (Section 7044, Business
and Professions Code).
❑ I, as owner of the property, am exclusively contracting with OWNERS Permit $ .94, D
licensed contractors to construct the project (Section 7044,
Business and Professions Code). AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED �jQCjf� ,
I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLy_5�,/
for the performance of the work for which this permit Is 16
issued (Sec. 3097, Civ. C.). SIGNED THIS DAY O
OWNER OR
Lender's Name OWNERS AGENT
ADDRESS
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
upo a aboq`( property for inspection purposes.
Si nature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE