HomeMy Public PortalAbout4833, 4825AGNES AVE_Sewer (14) WORKERS COMPENSATION DECLARATION 76 808 (Z 80) APPLICATION FOR PERMIT
(71K �
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
Insure or a certificate of Workers Compensation Insurance or
a certified c py thereof(Sec 3800 t C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
❑ Certified cop+is hereby furnished FOR APPLICANT TOF I LL IN CONNECTION DATA
BUILDING �� STATION �'�6 DEPTH 7
ertified copy is filed with the county building Inspection ADDRESS
---department ` PPER
LOCALITY C MANHOLE REFERENCE WER
Date ApallCant_T��(� -�� NREST TYPE OF CONNECTION LENGTH F M
CERTIFICATE OF EXEMPTION FROM WORKERS .:.SreY CURB P L M L To
COMPENSATION INSURANCEP c NO
OWNER /� CO IMP NO JOB NOMAIL
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(This section need not be completed if the work involved ADDRESSQTG � / TRUNK PERMIT NO ROAD PERMIT NO d
by the permit is for one hundred dollars ($100) Or less) AFF DAV T I WAVER EA EMENT RECORD -C-TR NO DATE U
CITA 'y TEL NOZW 7
I certify that in the performance of the work for which thisLEGAL
permit is Issued I shall not employ any person in any manner DESCRIPTION LOT No / HWY OR ST WIDENING
so as to become subject to the Workers Compensation Laws G,3 77 C.1
BLOCK TRACT STATE ENCROACHMENT LU
Date Applicant NO OF BLDGS PERMIT NO d
NOTICE TO APPLICANT If after making this Certificate of SIZE OF LOT NOW ON LOT NZ
Exemption USE of Z / —
p you should become subject to the Workers USE O N s o CHARGES
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be CONTRACTOR � �E� ,./ CONNECTION CHARGE FEE
deemed revoked
LICENSED CONTRACTORS DECLARATION JADDRESS �r REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter D TR a No GROU MA Oc ED B
9 (commencing with Section 7000) of Division 3 of the Aust CITY TEL NO B G
ness and Professions Code and my license is in full force and STATE
// LIC CLASS
/ Q
7
effect ICENSE NO J0b
NO DESCRIPTION OF WORK FEE
NOU E EWER CONNECT NG TO FINAL VALIDATION
License Number_ Lic Class {{II��� a C EWER DATE
\J ET C TANK EE AGE T OR
Contract o Date �'—�/�/ U T AND/OR DRA NF E O FINAL
HOU E EWER CONNECT NG TO BY
❑ I am exempt from the licensing requirements as I am a R VATS O O A Y TEM
CONNECT ADD T ONA BLDG OR
licensed architect or a registered profes tonal engineer WORK TO HOU E EWER
acting In my professional capacity (Section 7051 Bus OVERF OW BE AGE T ORA NF E D
mess and Professions Code) EXTN CE 00 DRYWE MANr10 E
A TER RE A R OR ABANDON HOU E
EWER OR D O A Y TEM
Lic 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
ness and Professions Code) HAVE AT TH DATE A CONTRACT W TH THE HERE 4. AiM.
D CON
❑ RACTOR TO CONNECT THE ABOVE DE CR BED EX TNG OWE LNG
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 2-4DAY OF
7044 Business and Professions Code) OWNER OR
AG
OWNER E
CONSTRUCTION LENDING AGENCY OWNER71 22331 A
I hereby affirm that there IS a construction lending agencyADORE _Z # o o Fo e 1
for the performance of the work for which this permit is 01
issued(Sec 3097 Civ C)
Lender s Name 2 o e 1 a 0 0
Lender s Address 0 0 0 18,0 0 C5
I certify that I have read this application and state that the
above Information is correct I agree to comply with all Courtv 0929-80
ordinances and State laws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon the above mentioned property for Inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ermitt Date