HomeMy Public PortalAbout4827 AGNES AVE_Sewer_9/29/1980_ WORKERS'COMPENSATION DECLARATION 76A642D APPLICATION FOR P E R M I T
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CE 808 (2 80)
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insur nce,or
a certified--opy thereof(Sec 3800 La Oc�_r COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No5L3_?_7L Company c u"'
79, FOR APPLICANT TO F LL IN It CONNECTION DATA
El Certified copy Is hereby furnished ;
g,department
BUILDING )A t' II STATION 6DEPTH ! 15
Certified copy is filed with the county building ins ectlon S � c� �J� UPPER
LOCALITY / '�wk MAN^LE REFERENCE // WERDate 2-� Appiicanta w a NEA � TYPE OF CONNECTION LENGTH FR
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSSIST �jQ'L�_/� Er Y CURB P L M L TO P �S
COMPENSATION INSURANCE +' ' J c No
OWNE �� C �I P+� OB NO
MAIL w�J .�
(This section need not be completed if the work Involved ADDRESS d1g;;- TRUNK PERMIT NO ROAD PERMIT NO }
by the permit Is for one hundred dollars (SI06) OI less) V
. ,�
I certify that in the performance of the work for which this LEGAL C._ , V
permit Is issued, I shall not employ any person in any manner DESCRIPTION OT NO HWY OR ST WIDENING tr
so as to become subject to the Workers'Compensation LawsQ
' BLOCK TRACT SA'S/ 7/��// STATE ENCROACHMENT
Date Applicant NO OFBLD GS PERMIT NO (�
W
NOTICE TO APPLICANT If, after making this Certificate of SIZE OF LOT NOW ON LOT d
Exemption, you should become subject to the Workers' USE of
Compensation BUILDINGS S Jy�� G SCO CHARGES Z
p provisions of the Labor Code, you must forth -/
with comply with such provisions or this permit shall be CONTRALTO ri%A CONNECTION CHARGE FEE
deemed revoked
REIMBURSEMENT FEE
ADDRESS
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter DISTRICT No GROUP MAP P eesseD BY
9 (commencingwith Section 7000 of Division 3 of the Busi CITY TEL No , 7 BK PG
ness and Professions Code, and my license is in full force and STATE /S8� LIC V'0 0
LICENSE NO
-effect G G� CLASS CL
(, NO DESCRIPTION WORK FEE
Q T NOOSE SEWER CONNECTCT ING TO FINAL ��, VALIDATION
License Number Lic Class - f PUBLIC SEWER DATE 9 /
//���T/J�
GIr/'�' SEPTIC TANK SEEPAGE PIT OR
Contractor Date ����/ PITS AND/OR DRAINFIELD
�
FINAL
HOUSE SEWER CONNECTING TO BY
❑ 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
loess and Professions Code) rlEXTN CESSPOOL DRYWELL MANHOLE
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNER'S Permit f
License Law for the following reason (Section 7031 5, Busi AUTHORIZATION TOTAL FEE
ness and Professions Code) 1 HAVE AT THISDATE A CONTRACT WITH THE HEREIN AIAkMED CON
OIRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING OWELLING
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 Z-4-- DAY OF
7044, Business and Professions Code) OWNER OR
OWNERS AGE -42335A
CONSTRUCTION LENDING AGENCY ADDRESS
I hereby affirm that Were is a construction lending agency # • •1• • 10
for the performance of the work for which this permit Is
issued(Sec 3097,Civ C) 2 • • Q
Lender's Name
Lender's Address • • • C c.J
I certify that I have read this application and state that the 0929—80
above information is correct I agree to comply with all County I
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorise representatives of this County to enter
upon the ab ve mentioned pro ty f inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatu f P;;p% Date