HomeMy Public PortalAbout4833, 4825AGNES AVE_Sewer (11) WORKERS COMPENSATION DECLARATION CE 808 (2 80) 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 In urance or
a certified copy thereof(Sec 3800 La ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Policy N � Company _ -e-
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Certified cop'7ls hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDIN /J� �/� �JSTATION � - � DEPTH
Certified copy is filed with the county building Inspection ADDRES
/ UPPER
-department '_`/J` -' LOCALITY G� MANHOLE REFERENCE OWER
Date-4-2---/ `� A licant N��T TYPE OF CONNECTION LENGTH OM
PI> > NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST O f�f Y CURB P L M L TO
COMPENSATION INSURANCE P C No
OWNER Co IMP NO JOB NOMAIL
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(This Section need not be completed if the Work involved ADDRESS ��{� TRUNK PERMIT NO ROAD PERMIT NO /a
by the permit is for one hundred dollars ($IOO) Or less) AFF DAV T WAVER EA EMENT RECORD N R NO DATE
CITY 6 TEL NO t?� Z U
1 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
F..
so as to become subject to the Workers Compensation Laws HWY OR ST WIDENING U
BLOCK TRACT STATE ENCROACHMENT W
Date Applicant NO OF BLDGS PERMIT NO d
N
NOTICE TO APPLICANT If after making this Certificate of SIZE OF LOT Now ON
Lor Z
Exemption you should become subject to the Workers USE OF
Compensation BUILDINGS CHARGES
p provisions of the Labor Code you must forth
with comply with Such provisions or this permit shall be CONTRACTOR .ls ff yti CONNECTION CHARGE FEE
deemed revoked �cJ
REIMBURSEMENT FEE
LIC>•.NSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter D TR CT No J�GROU31 MA eE ED B
9 (commencing with Section 7000)of Division 3 of the Busl carr TEL No BK G
ness and Professions Code and my license is in full force and STATE LICA /o—,
� e
effect LICENSE N CLASS
y !+ NO DESCRIPTION OF WORK FEE
License Number Lic Class DATE
HUB C EWER CONNECT N6 TO VALIDATION
b/
E T C TANK BE AGE TOR
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Contractor Date Vl FINAL OPA
HOU E EWER CONNECT NO O
IDI am exempt from the licensing requirements as I am a R VATS D O A Y TEM BY
licensed architect or a registered professional engineer WORK TO HOU E OEWER NA 0 OG OR
acting in my professional capacity (Section 7051 Bus OV- OW EE AGE T DRA NF E D
iness and Professions Code) E.T. CE 00 DR WE MANHO E
A TER RE A R OR ABANDON HOU E
//1•� 4 O�l EWER OR D O A BY TEM
Lic or Reg No (/05 G���f Date A'e O V
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 Busi AUTHORIZATION TOTAL FEE
ness and Professions Code) HAVE AT TH DATE A CONTRACT W TH THE HERE N NAMED CON
❑ TRACTOR TO CONNECT THE ABOVE OE CR BED EX T NO 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 �S�DAY OF
7044 Business and Professions Code) OWNER OR
ENT
CONSTRUCTION LENDING AGENCY OWNER AG2 3 3 8 A
I hereby affirm that there is a construction lending agency 11ADDRE
LP
for the performance of the work for which this permit is # D D D o 1 0
issued(Sec 3097 Civ C)
Lender s Name 2 D a 1 a O O
Lender s Address D - 18005
I certify that i have read this application and state that the
above Information Is Correct I agree to comply%ith all Courtv 0 929-80
ordinances and State laws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon th bove mentioned pro ert for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
SIgnatur f Permitt ate
A