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Home My Public Portal About4833, 4825AGNES AVE_Sewer (8) WORKERS COMI FNSATION DECLARATION 76A6420 CE 808 (2 80) APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL v/ Insure or a certificate of Workers Compensation In urance or a certified copy thereof(Sec 3800 v COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No�/327/ Company ' Certified copy�is hereby furnished FOR APPLICANT TO ILL IN CONNECTION DATA BUILDING �� pT10N 25�4DEPTH Certified copy Is filed with the unty builchng Inspection ADDRESS VVVV apartment LOCALITY OLE REFERENG yy 6 �d OWER Date0s Applicant NEAREST YPE OF CONNECTION LENGTH FROM �F CERTIFICATE OF EXEMPTION FROM WORKERS cRoss sT Y CURB P L M L ro P L / COMPENSATION INSURANCE _ O IMP NO JOB NO P C No � OWNE C } (This section need not be coni leted if the work involved ADDRESS Q/ / ` C' MAIL P Q G�p � TRUNK PERMIT NO ROAD PERMIT NO O by the permit is for one hundred dollars ($I00) or less) APF DAV 7 WAVER EA EMENT RECORD N TR NO DATE U CIT ;^Vf EL NO 0�A�Z7 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 O NWY OR ST WIDENING 0 so as to become subject to the Workers Compensation Laws U BLOCK TRACT 7 STATE ENCROACHMENT (V Date Applicant NO OFSLOGS PERMIT NO a Z NOTICE TO APPLICANT If after making this Certificate of SIZE OF LOT NOW ON LOT Z Exemption you should become subject to the Workers USE OF CHARGES Compensation provisions of the Labor Code BUILDINGS p p you must forth with comply with such provisions or this permit shall be � dam✓ y� CONNECTION CHARGE FEE deemed revoked CONTRACTor,,:-- REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS �i I hereby affirm that I am licensed under provisions of Chapter D TR CT No GROU MA a ED B 9 (commencing with Section 7000)of Division 3 of the Bust STATE CITY TEL No BK G ness and Professions Code and my license Is in full force and LICENSE NO „s CLASS `� �� effect S ` (p NO DESCRIPTION OF WORK FEE �� / HOU E EWER CONNECT NG TO FINAL' '1 SO� VALIDATION License Number Lie Class � uB C EWER DATE d� ��/ ^_ E T CT NK SEE AGE TOR Contrac r 9 ate r �Z_ ill vl T AND/OR ORA NF E D FIN HOUSE EWER CONNECT NG TO 0 R VATS D O A Y TEM I am exempt from the licensing requirements as I am a CONNECT ADD T DNA B OG OR LI licensed architect or a registered professional engineer WORK TO HOU E EWER acting in my professional capacity (Section 7051 Bus OVERF OW SEE AGE T ORA NF E Dl mess and Professions Code) EXTN CE oo DR we MANHo E A TER REA R OR ABANDON HOU E EWER OR D O A V TEM Llc 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 Bust AUTHORIZATION TOTAL FEE nese and Professions Code) HAVE A THDATE A CONTRACT W TH THE HERE N NAMED CON ❑ RACTOR TO CONNECT THE ABOVE DE CR BED EX T NG 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 SIGNED THIS —4--DAY OF r 7044 Business and Professions Code) OWNER OR :12330A OWNER CONSTRUCTION LI NDING AGENCY ADDRE I hereby affirm that there is a construction lending agency # D o D D 1 0 for the performance of the work for which this permit is Issued(Sec 3097 Civ C) 2 e D 1 a 0 0 Lender s Name Lender s Address D o D 1 8,0053 1 certify that I have read this application and state that the 0929-80 above Information is correct I agree to comply with all Courty ordinances and State laws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter upon,*e above mentioned property for inspec on purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Sign re of rmt a Date