HomeMy Public PortalAbout4833, 4825AGNES AVE_Sewer (13) 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