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Home My Public Portal About4833, 4825AGNES AVE_Sewer (15) WORKERS COMPENSATION DECLARATION 76A642D CE 808 (2 80) APPLICATION FOR P E R M I T 5� I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL Insure or a certificate of Workers Compensation In uran or a certified copy thereof(Sec 3800L COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No+z/-�97/ Company El 7 Certified copy Is hereby furnished FOR APPLICANT TO FI LL IN CONNECTION DATA BUILDING �J�f /JSTATION DEPTH Certified copy Is filed with the county building inspection ADDRESS //� fIf uPP R department / ' HOLE REFERENCE /�_/C27 / OWER LOCALITY G.� (JT l7� Date?-1--r" ApplicantAVL NEAREST YPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS cRoss ST Lp �-� L/� Y CURB P L M L TO P L �)/^ COMPENSATION INSURANCEP C NO OWNER /��I&/f CO IMP NO JOB NOMAIL } (This section need not be completed if the work involved ADDRESS A " �0 /may /P�� TRUNK PERMIT NO ROAD PERMIT NO CL by the permit is for one hundred dollars ($100) or less AFF DAV T WAVER EA EMEN RECORD N TR NO DATE U CITY TEL NO Z &_27 0 I certify that In the performance of the work for which thisLEGAL Cc permit is issued I shall not employ any person in any manner DESCRIPTION LOT NO / HWY OR ST WIDENING 0 so as to become subject to the Workers Compensation Laws U BLOCK TRACT STATE ENCROACHMENT LU Date Applicant NO OF BLOGS PERMIT NO d 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 BUILDINGS CHARGES Compensation provisions of the Labor Code you must forth with comply with such provisions or this permit shall be ! CONNECTION CHARGE FEE deemed revoked CONTRACTOR �y �G6 LICENSED CONTRACTORS DECLARATIONADDRESS REIMBURSEMENT FEE I hereby affirm that I am licensed under provisions of Chapter D TR CT NO GROu MA ED Y NO K 9 (commencing with Section 7000)of Division 3 of the Busi CITY TEL - < Hess and Professions Code and my license Is In full force and STATE L effecCENSE NoZlo,�8�� class �Q(� Q� G Bv /t� ! !! Y T NO DESCRIPTION OF WORK FEE F NA License Number Llc Class— HOU E EWER CONNECT NG TO DATE VALIDATION UB C EWER — E T C TANK EE AGE TOR Contract0 Date T AND/OR ORA NF E O FINAL HOU E EWER CONNECT NG TO BY I am exempt from the licensing requirements as I am a R VATE D OSA TEM ICONNECT ADD T DNA B OG OR licensed architect or a registered profes venal engineer WORK TO HOU E EWER acting in my professional capacity (Section 7051 Bus OVENOW EE AGE T DRA NF E D mess and Professions Code) EXTN CE 00 ORYWE MANNO E A TER RE A R OR ABANDON HOU E EWER OR D O A TEM Lic or Reg No Date HOME OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors OWNERS Permit S License L-w 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 ❑ RACTOR TO CONNECT THE ABOVE OE CR BED E% T NG OWE NG I as owner of the property will do the work and the TO THE 8C EWER structure Is not Intended or offered for sale (Section SIGNED THIS (r DAY OF 14, R 7044 Business and Professions Code) OWNER O OWNER AGE tA CONSTRUCTION LENDING AGENCY ADDRE 2 2 3 3 6 A I hereby affirm that there is a construction lending agency for the performanceof the work for which this permit is # D D Io o 1 0 issued(Sec 3097 Civ C) Lender s Name 2 e D 1 a Q o Lender s Address 00 D 1 S Q Q v I certify that I have read this application and state that the above Information is correct I agree to comply with all Courty 0 9 29—8 O ordinances and State laws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter upon the above mentioned property for ins ection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Z9� a Signature �ermlt a Date