HomeMy Public PortalAbout4831AGNES AVE_Sewer WORKERS COMPENSATION DECLARATION CE 808 (2 80) APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insure or a certificate of Workers Compensatiqp In urance or
a certified copy thereof(Sec 3800 b C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No's A97/ Company �a,, A—��•
CertifPed opy i
J9 s hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
c
BUILDING /� / STATION DEPTH
�ertified copy is filed with the��Icounigt building inspection ADDRESS UPP
department LOCALITY G MANHOLE REFERENCE �/ /N
Date `� Applicant ,—LLG�+ •� — NG wER
�� NEAREST / TYPE OF CONNECTION LENGTH F O
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST G r CURB P L M L To P
COMPENSATION INSURANCE P C No
OWNER fj CO IMP NO JOB NoMAIL
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(This section need not be completed if the work involved ADDRES // a
P �$6 /�� a TRUNK PERMIT NO ROAD PERMIT NO O
by the permit is for one hundred dollars ($100) or less) AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE U
CITES, �jV, TEL NO C��7
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 / O
HWY OR ST WIDENING 0
so as to become subject to the Workers Compensation Laws
BLOCK TRACT / STATE ENCROACHMENT W
Date Applicant NO OF BLOGS PERMIT NO d
SIZE OF LOT NOW ON LOT
NOTICE TO APPLICANT If after making this Certificate of Z
Exemption USE OF �
p you should become subject to the Workers BUILDINGS_moi � C /1CHARGES
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be CONTRACTOR rA�/�► CONNECTION CHARGE FEE
deemed revoked / REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS J`
I hereby affirm that I am licensed under provisions of Chapter DISTRICT No GROUP MAP O ESSEO BY
CITY TEL NO BK PG
9 (commencing with Section 7000)of Division 3 of the Bust I
STATE ness and Professions Code and my license is in full force and LICENSE No2G CLASS �(/v
effect NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO FINAL A` "` VALIDATION
License Number Lic Class PUBLIC SEWER DATE 7 JV�IV)
�j SEPTIC TANK SEEPAGE PIT OR )
Contractor Date -�r PITS AND/OR DRAINFIELD FINA
HOUSE SEWER CONNECTING TO
a 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
mess and Professions Code) EXTN CESSPOOL DRYWELL MANHOLE
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
Lic or Reg N --Date G
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors OWNERS Permit f
License Law for the following reason (Section 7031 5 Bust AUTHORIZATION TOTAL FEE I Ilk —
ness
and Professions Code)
I HAVE T THIS OATS A CONTRACT WITH THE HEREIN NAMED CON
El
IRA CTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
I as owner of the property will do the work and the TO THE PUBLIC SEWER p
structure is not intended or offered for sale (Section SIGNED THIS L�DAY OF / 19
7044 Business and Professions Code) OWNER oR
OWNERS AGE 2 3 2 4 A
CONSTRUCTION LENDING AGENCY ADDRESS
I hereby affirm that there is a construction lending agency # B B B B 1 0
for the performance of the work for which this permit is
issued(Sec 3C97 Civ C)
Lender s Name 219 B 1 a Q Q
Lender s Address s B B 1 8 0 o x,
I certify that I have read this application and state that the 0929-80
above information is correct I agree to comply with all Courty
ordinances and State laws regulating Plumbing and Sewers
and hereby authorize representatnes of this County to enter
upon the a ove mentioned pert y for ction purposes
�� yf�O' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa tu f Perm ee Date