HomeMy Public PortalAbout4833, 4825AGNES AVE_Sewer WORKERS COMPENSATION DECLARATION D
CE 808
t:l_s0sczs0l 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 Insurance gr
a certified opy the e f(Sec 3800 La COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N 3�7 Company
� FOR APPLICANT70 FILL IN CON CTION DATA
Certified copy 1s hereby furnished BUILDINs
ADDRESG c STATION 1 -,-,—,94P DEPTH
�ertified copy Is filed with the cou ty bulldtog Inspection (/ PPER
apartment MANHOLE REFERENCE4<25¢y ,
Date/1-1—fou LOCALITY v �,r,ZO
Applicant NEAREST TYPE OF CONNECTION LENGTH FROM LT
CERTIFICATE OF EXEMPTION FROM WORKERS ci:oss sT� 6 its r cu RB P L M L TO P L a
COMPENSATION INSURANCE P c NO
OWNER CG- CO IMP NO JOB NO
MAIL(This section need not be completed If the work Involved ADDRESS`
TRUNK PERMIT NO ROAD PERMIT NO
by the permit is for one hundred dollars ($IOU) or less)
AFF DAV T I WAVER EA EMEN RECORD N T NO DATE d
I certify that In the performance of the work for which this cI LEGAL
GL TEL No ZB7 0
permit is Issued I shall not employ any person In any manner DESCRIPTION LOT NO / HWY OR ST WIDENING Ir
so as to become subject to the Workers Compensation Laws �63 77 O
BLOCK TRAC STATE ENCROACHMENT
Date-Applicant No OF SLOGS PERMIT NO VLLJ
4NOTICE 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 .q CHARGES
Compensation provisions of the Labor Code BUILDINGS
P p you must forth
with comply with such provisions or this permit shall be CONTRACT �/cr/�G 6 [ l CONNECTION CHARGE FEE
deemed revokes
REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS
1 hereby affl m that I am licensed under provisions of Chapter D TR eT No GROU MA Roe EO BY
9 (commencing with Section 7000)of Division 3 of the Buss CITY TEL No
ness and Professions Code and my license is In full force and STATE ? /
LIC
LICENSE NO G e(��8� CLASS
effect r l (r/ NO DESCRIPTION OF WORK FEE
J / ,� / / HOU E EWER CONNEC NG TO FINAL/ ` VALIDATION
License Number LIc Class UB C EWER DATE —'
E T C TANK BE AGE TOR
or
Contrac Date 'P — Z T AND/OR ORA NF E D FIN
HOU E EWER CONNECT NG TO
D R VATS D O A Y TEM BY
I am exempt from the licensing requirements as I am a
CONNECT ADO TOE B DG OR 2 1 _�
licensed architect or a registered professional engineer WORK TO HOU E EWER 7�'3' O
acting in my professional capacity (Section /051 Bus OV ERF OW EE AGE T DRA NF E D
E%TN CE 00 ORYWE MANNO E -rMA o o
mess and Professions Code) o x
A TER RE A R OR ABANDON HOU E
"J /�! / - EWER OR O O AL YSTEM
LIc or Reg N0/rG/�S 6 NI Date G (� 2 9i 8 Q
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
ness and Professions Code) HAVE AT THDATE A CONTRACT W TM THE MERE N NAMED CON
❑ RACTOR TO CONNECT THE ABOVE DE CR BED EX T NG DWE NG
I as owner of the property will do the work and the TO THE UB C EWER �s
structure is not Intended or offered for sale (Section SIGNED THIS Z DAY OF ' / Ise0 b
7044 Business and Professions Code) OWNER OR 0
OWNER N ^/ /n{
CONSTRUCTION LENDING AGENCY ADDRE A 2
I hereby affirm that Were Is a construction lending agene,y 2 1 O O O
for the performance of the work for which this permit is
Issued(Sec 3097 Civ C)
Lender s Name o 1 QI 8 0 0 5
Lender s Address o 0 0 Nn 9291-80
I certify that I have read this application and state that the N o 0 o N
above Information is correct I agree to comply with all Courty �O —� c C4
ordinances and State laws regulating Plumbing and Sewers 1 QD Co o N
and hereby authorize representatives of this County to enter OD O O ==1 -O
upon the above mentioned property for inspection purposes O O O O D>
�rZ9ZSEE REVERSE FOR EXPLANATORY LANGUAGE CH
a
Signatur Per ee Date