HomeMy Public PortalAbout6326 AGNES AVE_Sewer_11/17/1980_ WORKERS'COMPENSATION DECLARATION CE 808 (D2 80) 7'e c A P P L_I C AT I O N FOR PERMIT
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insure or a certificate of Workers'Compensation Insurance,or I "fl
a certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
Certified copy Is hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING STATION DEPTH
Certified c0 ADDRESS ti e— UPPER
copy is filed with the county building inspection
department LOCALITY MANHOLE REFERENCE
LOWER
Date Applicant NEAREST TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST Y CURB P L M L TO P L
COMPENSATION INSURANCE 9 c No
OWNER CO IMP NO JOB NOMAIL
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(This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO ROAD PERMIT NO d
by the permit is for one hundred dollars ($100) or less) AFFIDAVIT WAVER EASEMENT RECORD INSTR NO DATE O
CITY `O P Gi TEL NO 2&(o 3`3 cc
I certify that in the performance of the work for which this LEGAL
permit is Issued I shall not employ any person in any manner DESCRIPTION LOT NO 0
HWY OR SI WIDENING
so as to become subject to the Workers Compensation Laws CU
BLOCK TRACT yrs ON LOT z
NOSTATE ENCROACHMENT LU
Date Applicant NO SIZE OF LOT W OF BLDGS PERMIT NO U)
NOTICE TO APPLICANT If after making this Certificate of Z
Exemption you should become subject to the Workers USE OF
Compensation BUILDINGS CHARGES
p provisions of the Labor Code, you must forth
with comply with such CONNECTION CHARGE FEE
p y provisions or this permit shall be CONTRACTOR
deemed revoked
LICENSED CONTRACTORS DECLARATION ADDRESS A I
REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter DISTRICT No GROUP MAP PRO ESSED BY
CITY TEL No BK PG
9 (commencing with Section 7000) of Division 3 of the Busl
ness and Professions Code, and my license is in full force and STATE LIC
LICENSE NO CLASS
effect
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO VALIDATION
License Number Lic Class PUBLIC SEWER DATE I/
SEPTIC TANK SEEPAGE PIT OR
PITS-./OR DRAINF I ELD
Contractor Date FINAL
HOUSE SEWER CONNECTING TO BY
El PRIVATE DISPOSAL SYSTEM
I am exempt from the licensing requirements as I am a
CONNECT ADDITIONAL BLDG OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER \
acting in my professional capacity (Section 7051 Bus OVERFLOW SEEPAGE PIT DRAINFIELD
iness and Professions Code) E.TN CESSPOOL DRYWELL MANHOLE
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION �?3 1' 0 4 A
I hereby affirm that I am exempt from the Contractor's OWN ER$ Permit f
License Law for the following reason (Section 7031 5 Busi AUTHORIZATION TOTAL FEE $ 0 0 0 0 1
ness and Professions Code) 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON I�
IRACTOR O CONNECT THE ABOVE DESCRIBED EXISTING DWELLING O O 1 BOO T
I as owner of the property will do the work and the TO THE PUBLIC SEWER
structure is not Intended or offered for sale (Section SIGNED THIS DAY OF 19 0 a a 1 8 0 0
7044, Business and Professions Code)
OWNER OR
1
CONSTRUCTION LbOWNERS AGENT 124-80
NDING AGENCY ADDRESS
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec 3097 Civ C)
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 a orize representa es of this County to enter
upon the ab mentioned pro a for inspection purposes
J � SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee QV