HomeMy Public PortalAbout4833, 4825AGNES AVE_Sewer (9) WORKERS COMPENSATION DECLARATION 76A642D f/J
CE 808 (280) APPLICATION FOR PERMIT .(J
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
Insure or a certificate of Workers Compensation Insuranc r
a certified opt+thereof(Sec 3800 La COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N 7� Company-
Certified cops hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING /1 STATION DEPTH /
Certified copy Is filed with the count ADORES:inspection ADORES: 7�,�f � /y — ��
Certified
/ MANHOLE REFERENCE ��j 1J PER
LOCALITY C� d , L R
Datgz i —/—Tl) Applicant NEAREST
TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS ceoss sr �Q yl/ � „s r cues P L M L ro P L
COMPENSATION INSURANCE P C No
OWNER CO IMP No JOB NO
MAIL
(This section need not be completed if the@work involved ADDRESS ® U TRUNK PERMIT NO ROAD PERMIT NO �.
by the permit is for one hundred dollars ($100) Or less) AFF DAV T I WAVER EA EMENT RECORD N TR NO DATE O
CITY TEL NO z
I certify that in the performance of the work for which this LEGAL / U
permit Is issued I shall not employ any person in any manner DESCRIPTION LOT NO HWY OR ST WIDENING 1c
so as to become subject to the Workers Compensation Laws // � 0
BLOCK TRACT�63 � STATE ENCROACHMENT
Date Applicant NO OF BLDGS PERMIT NO U
IL
NOTICE TO APPLICANT If after making this Certificate of SIZE OF LOT NOW ON LOT tl
Exemption USE OF t/)
p you should become subject to the Workers BUILDINGS a^f CHARGE: Z
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be CONTRACTOR �6 CONNECTION CHARGE FEE
deemed revoked
LICENSED CONTRACTORS DECLARATION ADDRESS �% REIMBURSEMENT FEE
I hereby affl in that I am licensed under provisions of Chapter o TR C NO GROU MA Roc ED
9 (commencing with Section 7000) of Division 3 of the Bust
clTr TEL No BK G
ness and Professions Code and my license is In full force and STATE Llc /�!'
LICENSE NO `j CLASS / �(/ 0--3
effect NO DESCRIPTION OF WORK FEE VALIDATION
MOU E EWER CONNECT NG TO ) FINAL �i ((��//��
License Number_ Lie Class us C EWER / DATE
(�\ E T C TANK BE AGE T OR A
Contractor Liv Date —2-0 T AND/OR ORA NF E D FINAL
HOU E EWER CONNECT NG TO
R VATS D O A SY EM BY
I am exempt from the licensing requirements as I am a
CON ECT ADDY 0
licensed architect or a registered professional engineer WORK TO HOU E DNAEWERDG OR
acting in my professional capacity (Section 1051 BUS OVERF OW BE AGET DRA NF E D
mess and Professions Code) 11XTN CO 00 ORYWE MANHO E
7 A TER RE A R OR ABANDON HOU E
LIC or Reg Noo sw` 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 f
License Law for the following reason (Section 7031 5 Bust AUTHORIZATION TOTAL FEE
ness and Professions Code) HAVE AT TH DATE A CONTRACT W TH THE HERE N NAMED CON
IDRACTOR 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 US C EWER
structure Is not Intended or offered for sale (Section SIGNED THIS Z -4 DAY OF 19AO
7044 Business and Professions Code) OWNER OR I
pz2326
ER A
O
CONSTRUCTION LLNDING AGENCY pWNW--R # D O D O l A
DDRE
I hereby affirm that tnere IS a construction lending agency
for the performance of the work for which this permit Is
issued(Sec 3097 Civ C) `1 0 0 Q
Lender s Name
Lender s Address o o D 1 8.005
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 Courty
ordinances and State laws regulating Plumbing and Sewers
and hereby authoriLe representatives of this County to enter
upon the above mentioned property for inspection purposes
SEE REVERSE 17OR EXPLANATORY LANGUAGE
Sign a of
t;p7 Date