HomeMy Public PortalAbout4831AGNES AVE_Sewer (5) WORKERS COMPENSATION DECLARATION CE 8 82
(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 Compensation Insuran,4 or
a certified opy thereof(Sec 3800 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N.JZ3-f7/ Company
79 FOR APPLICANT TO FILL IN CONNECTION DATA
Certified copy is hereby furnished BUILDING _ STATION!L.� DEPTH
�� \V�/
Certified copy is filed with t/he1 county bu44ding Inspection AUPP
DDRESS
department LOCALITY G / MANHOLE REFERENCE--:!�J
Date/z—/—,-, v Applicant �+r�. wER
PP NEAREST TYPE OF CONNECTION LENGTH F
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS sT CURB P L . 1 To P
COMPENSATION INSURANCE P C NO _
OWNER CO IMP NO JOB NO 71
MAIL
(This section need not be completed if the work involved ADDRESS49991rz: / TRUNK PERMIT NO ROAD PERMIT NO }
by the permit is for one hundred dollars ($100) or less) AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE n'
CITY TEL NO V
1 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 HWY OR ST WIDENING it
so as to become subject to the Workers Compensation Laws / J'�� Q
BLOCK TRACT ,---?77/ STATE ENCROACHMENT
Date Applicant NO OFBLOGS PERMIT NO (�
NOTICE TO APPLICANT If after making this Certificate of SIZE OF LOT NOW ON LOT d
Exemption you should become subleLt to the Workers USE of / CHARGES Z
Compensation provisions of the Labor Code you must forth BUILDIN /
with comply with such provisions or this permit shall be CONTRACTOR /'/� CONNECTION CHARGE FEE
deemed revokes Jam'
REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby afft m CITY TEL No BK PG
that I am licensed under provisions of Chapter DISTRICT NO EP
MAP sseD BY
9 (commencing with Section 7000) of Division 3 of the Busi
Hess and Professions Code and my license Is In full force and STATELICENSE NO X86 CLASS ' UO
effect NO DESCRIPTION OF WORK FEE /}/J
HOUSE SEWER CONNECTING TO FINALe'8�// S'Y/(/ VALIDATION
License Number Lic Class VVVJJ/ PUBLIC SEWER DATE ®� P
SEPTIC TANK SEEPAGE PIT OR
Contract o2 Date S+W (J 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 1051 Bus OVERFLOW SEEPAGE PIT DRAINFIELD
mess and Professions Code) EXTN CESSPOOL ORYWELL 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 f
License Law for the following reason (Section 7031 5 Busi AUTHORIZATION TOTAL FEE
nese and Professions Code) I HAVE AT THIS DATE 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 Z DAY OF t9
7044 Business and Professions Code) OWNER DR 2 3 3 4 A
OWNERS AG
CONSTRUCTION LENDING AGENCY ADORess
1 hereby affirm that tnere is a construction lending agency # B O'S • 1 0
for the performance of the work for which this permit Is
Issued(Sec 3097 Civ C) 2 B B 1 8 0 0
Lender s Name
Lender s Address t B 00
l Q Q 0 V
I Lertify that i have read this application and state that the Q 929-80
above information is correLt I agree to comply with all Courty
ordinances and State laws regulating Plumbing and Sewers
and hereby authoriz4 representatives of this County to enter
upon the above mentioned property for pection purposes
SEE REVERSE 1 OR EXPLANATORY LANGUAGE
Signatur Permit e Date � �d