HomeMy Public PortalAbout4831AGNES AVE_Sewer (3) WORKERS COMPENSATION DECLARATION D
CE 808 (2 80) APPLICATION FOR PERMIT
CE 808
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
Insure or a certificate of Workers Compensation Insurance or
a certified Lopy thereof(Sec 3800 LaCOUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N 4a rr Company 4
7� FOR APPLICANT TO FILL IN CONNECTION DATA
Certified copy?s hereby furnished
BUILDING Al TION DEPTH J
Certified copy is filed with the county building Inspection ADDRESS ,v UPPE
epartment MANHOLE REFERENCE ,3 / O a
LOCALITY
Date Jl--f —S'1' ApplicantT - NEAREST TYPE OF CONNECTION LENGTH FR OWER
CERTIFICATE OF EXEMPTION FROM WORKERS cRoss sr r cuws P L M L TOP /
COMPENSATION INSURANCE P C No
OWNER �/�� CO IMP NO JOB NO
MAIL G
(This section need not be completed if the work IRVOIVed ADDRESS TRUNK PERMIT NO ROAD PERMIT NO }
by the permit is for one hundred dollars ($100) or less) /✓ a
S O t?�' AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE O
CITY L NO
1 certifythat in the U
performance of the work for which this LEGAL /
permit is Issued I shall not employ any person In any manner DESCRIPTION LOT NO HWY OR ST WIDENING
so as to become subject to the Workers Compensation Laws / '7 O
BLOCK TRACT �+�7/ STATE ENCROACHMENT
Date Applicant NO OF SL
SIZE OF LOT OW ON LOT PERMIT NO (�
N
NOTICE TO APPLICANT If after making this Certificate of
Exemption you should become subject to the Workers USE OF
/ Yy/'� �p-�s/ CHARGES Z
Compensation provisions of the Labor Code you must forth
with comply with such l /I��,�� .�.j CONNECTION CHARGE FEE
p y provisions or this permit shall be CONTRACTOR Q (�1� �f/
deemed revokea
r REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS ./. Jr
I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO GROUP MAP Ro SSED BY
ciry TEL No BK PG
9 (commencing with Section 7000)of Division 3 of the Bust
Hess and Professions Code and my license Is to full force and STATE LICENSE N�p 04 CIC SS
effect � /y} FINAL VALIDATION
NO DESCRIPTION OF WORK FEE /B //���
✓lJ(�Osv ��f HOUSE SEWER CONNECTING TO
License Numb r LIc Class PUBLIC SEWER DATE ®r/
C Date SEPTIC TANK SEEPAGE PIT OR
Contracto
���I /1 �r� PITS AND/OR DRAINFIELD FINAL
(�(7 rN HOUSE SEWER CONNECTING TO
Q PRIVATE DISPOSAL SYSTEM BY
I am ex fmpt 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 (Sectior 1/051 Bus OVERFLOW SEEPAGE PIT DRAINFIELD /
iness and Professions Code) EXTN CESSPOOL OR Y.E" 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 Contractors
OWNERS Permit 9
License Law for the following reason (Section 7031 5 Bust AUTHORIZATION TOTAL FEE
nes:and Professions Code) I HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON
❑ IRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
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 27r DAY OF ' _
19 Bd
7044 Business and Professions Code) OWNER OR
OWNERS A6 2 3 3,3 A
CONSTRUCTION LI ND1NG AGENCY ADDRESS
I hereby affirm that tnere Is d construction lending agency # B B B • 1,0
for the performance of the work for which this permit Is
issued(Sec 3097 Civ C)
Lender s Name 2 • • 1 a 0 0
Lender s Address • • • 1 a 00:X
I certify that I have read this dppllcdtion and state that the I
above Information is correct I agree to comply with all Courty 0 929-80
ordinances and State laws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon the bove mentioned property for Inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa a of r/;7
e itte Date