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Home My Public Portal About4833, 4825AGNES AVE_Sewer (4) WORKERS COM ENSATION DECLARATION 76A642D CE 808(280) 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 Insuranc or a certified_opy thereof(Sec 3800 COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N-5-11g Company, ,� FOR APPLICANT 10 FILL IN CONNECTION DATA Certified copy Is hereby furnished BUILDING STATION DEPTH WCertified copy is filed with the county building Inspection ADDRESS �,r —"-department UPPER Date/Z—f ted" LOCALITY � G� MANHOLE REFERENCE �J,J�/ � f(/ OWER Applicant NEAREST TYPE OF CONNECTION LENGTH F CERTIFICATE OF EXEMPTION FROM WORKERS Clross sr m_ Y CURB P L - 1 ro COMPENSATION INSURANCEP C No OWNER �• CO IMP NO JOB NO MAIL } (This section need not be completed if the work Involved ADDREg1�� Q/I� TRUNK PERMIT NO ROAD PERMIT NO by the permit is for one hundred dollars ($100) or less) AFF DAV T WAVER EA EMENT RECORD N TR NO DATE O TEL NO tJ7 I certify that in the performance of the work for which this LEGAL \ V permit is issued I shall not employ any person in any manner DESCRIPTION LOT NoHwv OR sr WIDENING U W so as to become subject to the Workers Compensation Laws / O BLOCK TRACX-5, STATE ENCROACHMENT Date Applicant NO OF BLDGS PERMIT NO (� SIZE OF LOT NOW ON LOT W NOTICE TO APPLICANT If after making this Certificate of a Exem tion USE DI �� /� p you should become subject to the Workers USEBUIO N s �t� CHARGES Z Compensation provisions of the Labor Code you must forth _ with comply with such provisions or this permit shall be �li��i, /�� CONNECTION CHARGE FEE CONTRACTOR /y` deemed revoked LICENSED CONTRACTORS DECLARATION ADDRESS �r REIMBURSEMENT FEE I hereby affi m that I am licensed under provisions of Chapter D TR CT NO GROU MA ED BY 9 (commencing with Section 7000)of Division 3 of the Busi clrY TEL No BK G ness and Professions Code and my license is in full force and STATE r /�r LIC effect LICENSE NO i� d' CLASS v (� 1-6 NO DESCRIPTION OF WORK FEE ��/ HOU E EWER CONNECT NG TO FINAL ' —� f�.ti1 VALIDATION License Number Lic Class JJJ uB C EWER DATE (J � / �,/� E T C TANK BE AGE T OR Contractor Date 7/ —2 IG/ -AZO T AND/OR ORA NF E D FINAL 0 HOU E EWER CONNECT NG TO BY ♦/1�ysrj �� F1I am exempt from the licensing requirements as I am a R VATS D O A Y TEM CONNECT ADD T DNA B OG OR licensed architect or a registered professional engineer WORK TO HOU E EWER acting in my professional capacity (Section 1051 Bus OVERF OW EE AGET ORA NF E O iness and Professions Code) EXTN CE 00 CRY WE MANHO E A TER RE A R OR ABANDON HOU B ��f y �J O SEWER OR O O A Y TEM Lic or Reg No a/V—� Date HOME OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor s OWNERS Permit f 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 MERE N NAMED CON ORACTOR TO CONNECT THE ABOVE DE CR BED EX TNG OWE NO 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 SIGNED THIS Z_&__DAY OF 19c�id 7044 Business and Professions Code) OWNER OR OWNER AGEN CONSTRUCTION LENDING AGENCY ADDRE 2 3 2 5 A I hereby affirm that tnere is d construction lending agency 0 for the performance of the work for which this permit is # D DID D issued(Sec 3097 Civ C) Lender s Name 2 D D 1 8.00 Lender s Address 00 D 1 a 0 0 5) I certify that I have read this dpplicdtion and state that thL above Information is correct I agree to comply with all Coui ty 0929-80 ordinances and State laws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter upon the ab ve mentioned property f in pection pur oses Z SEE REVERSE FOR EXPLANATORY LANGUAGE Signature Perini a Date