HomeMy Public PortalAbout4833, 4825AGNES AVE_Sewer (3) WORKERS COMPENSATION DECLARATION D
CE 808 (2 80) APPLICATION FOR P E R M IT Z� `, I
CE 808 U
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
Insure or a certificate of Workers Compensation Insuranc or
a certified opy thereof(Sec 3800 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Z l Company.
C1Certifiedcopy Is hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING r ��� STATION �'� DEPTH 7
Certified copy is filed with the county building inspection ADDRESS G PPER
bb`"' ddepartment a LOCALITY G M HOLE REFERENCE,
e Z�
Applicant NEAREST TYPE OF CONNECTION LENGTH FRO
DatA
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS
ST L® �,��s79 Y CURB P L M L TO P L
COMPENSATION INSURANCE P C NO
OWNER / �- CO IMP NO JOB NO
(This section need not be completed if the work involved MAIL
ADDRESS s
P dOP TRUNK PERMIT NO ROAD PERMIT NO
by the permit is for one hundred dollars ($100) Or less) �� AFF OAV T WAVER EA EMENT RECORD N TR NO DATE O
CITY TEL NO V
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 / HWY OR ST WIDENING
so as to become subject to the Workers Compensation Laws O
S BLOCK TRACT STATE ENCROACHMENT
Date Applicant NO OF SLOGS PERMIT NO (�
SIZE OF LOT NOW ON LOT UJ
NOTICE TO APPLICANT If after making this Certificate of d
Exemption you should become subject to the Workers USE OF E� J CHARGES U)
Compensation provisions of the Labor Code you must forth BUILDIN s ((d
with comply with such provisions or this permit shall be CONTRACTOR G �•O CONNECTION CHARGE FEE
deemed revoked /y REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS J`
I hereby affirm that I am licensed under provisions of Chapter D TR CT NOGROU MA R E ED BY
9 (commencing with Section 7000)of Division 3 of the Busl CITY TEL NO f BK G
Hess and Professions Code and my license is to full force and
STAY ELICENSE NO �s CLCAss �9
effect G NO DESCRIPTION OF WORK FEE
� HOU E EWER CONNECT NG TO FINAL VALIDATION
License Number_ Lic Class U C EWER DATE
/ // (''7'J E T C TANK EE AGE TOR
Contractor Date / —�6 V T AND/OR ORA NF E D FINAL
HOU E EWER CONNECT NG TO BY
❑ I am exempt from the licensing requirements as 1 am a
CON ECT ADD T B
RV ATS D O A Y TEM
licensed architect or a registered professional engineer WORK TO OU E DNAEWER
DG OR
acting In my professional capacity (Section /051 Bus OVERF OW EE AGE T ORA NF E D
mess and Professions Code) EXTN CE 00 ORYWE MANHO E
/` /` /yam �J A TER RE A R OR ABANDON HOU E
Lic or Reg No
�
�`� �'�( Date �/ Q EWER OR D O A Y TEM
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors
OWNERS Permit SI 41
License Law for the following reason (Section 7031 5 Busi AUTHORIZATION TOTAL FEE
ness and Professions Code)
HAVE AT TH DATE A CONTRACT W TH THE HERE N NAMED CON
E3RACTOR TO CONNECT THE ABOVE DE CR BED EX TNG OWE NG
I as owner of the property will do the work and the TO THE UB C EWER
structure is not Intended or offered for sale (Section IS
IGNED THIS DAY OF 19
7044 Business and Professions Code) OWNER OR 2 3 21 A
OWNER AGE
CONSTRUCTION LENDING AGENCY ADDRE
I hereby affirm that Were IS a construction lending agency # o O D D 1 Q
for the performance of the work for which this permit is
issued(Sec 3097 Civ C) 2 0 0 1
Lender s Name
8.00
Lender s Address DDB 1 8 p
I certify that I have read this application and state that the 0 929-80
above information Is correct I agree to comply with all County f
ordinances and State laws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon the above mentioned property for pection purposes
oeQ o SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ermlt a Date O