HomeMy Public PortalAbout4833, 4825AGNES AVE_Sewer (16) WORKERS COMPENSATION DECLARATION D
CE 808 (2 80) APPLICATION FOR P E R M I T
CE 808
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 Lak C= COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No'57 9941 Company
El Certified copy s hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING � 6/!�� STATION <5;4- DEPTH '�
Certified copy Is filed with the county building inspection ADDRESS �b UPPER
\ partmern_t. - / MANHOLE REFERENCE
'2`/—w LOCALITY G.� �1CV7�2) OWE
Date Applicant NEAREST YPE OF CONNECT LENGTH F M /
CERTIFICATE OF EXEMPTION FROM WORKERS ceoss sr LAS cuw6 P M L TOP L
COMPENSATION IN URANCE P C NOOWNER le Cy% CO IMP NO JOB No —
MAIL
(This section need not be ADDRESS completed if the work involved /+-
P ���� c .sr �/ � TRUNK PERMIT NO ROAD PERMIT NO }
by the permit is for one hundred dollars ($100) or less) a
AFP DAV T WAVER EA EMENT RECORD N R NO DATE
CITY sA TEL NO �� O
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 W
so as to become subject to the Workers Compensation Laws Q
BLOCK TRACT STATE ENCROACHMENT 77
Date Applicant NO OF BLDGS PERMIT NO (�
SIZE OF LOT NOW ON LOT LU
NOTICE TO APPLICANT If after making this Certificate of CL
Exemption you should beLome subject to the Workers USE OF C CHARGES U)
Compensation provisions of the Labor Code you must forth BUILDINGS
with comply with such provisions or this permit shall be CONTRACTOR G '�� CONNECTION CHARGE FEE
deemed revoked /
LICENSED CONTRACTORS DECLARATION ADDRESS REIMBURSEMENT
REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter D TR CT No GRou MA a ED B
9 (commencing with Section 7000) of Division 3 of the Busl clrY _ TEL No BK G
ness and Professions STATE o��6 LIC
ffect Code and my license Is In full force and LICENSE N CLASS
e
NO DESCRIPTION OF WORK FEE
License Number Lic Class- 63-1_-/ HOUBE EWER CONNECT NG TO FINAL r VALIDATION
UB C EWER
E T C ANK EE AGE T OR
T AND/OR DRA NF E D
ntractor Date � � FINALK
HOU E EWER CONNECT NO TO
❑ R VATS D O A TEM BY I
I am exempt from the licensing requirements as I am a CONNECT ADD DNA B DG OR
licensed architect or a registered professional engineer WORK TO Hou E EWER
acting in my professional capacity (Section /051 Bus OVERF OW BE AGE T ORA NF E D
mess and Professions Code) EXTN CE 00 DRVWE _MAN 40
E
ATER RE A R OR ABANDON HOU E
Ord-`
�^' J /Aa�-- T EWER OR D O A Y TEM
Lic or Reg No l� �/ Date V
HOME OWNhR 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 THDA E A CONTRACT W TH THE HERE N NAMED CON
O RACTOR TO CONNECT THE ABOVE DE CR BED EX T NG OWE NG
1 as owner of the property will do the work and the ITO
THE UB C EWER
structure is not intended or offered for sale (Section SIGNED THIS DAY OF 10, fOrr
7044 Business and Professions Code) OWNER OR 2fff
2 3 2 2 A
OWNER AGENT
CONSTRUCTION LENDING AGENCY ADDRES # O 010 O 1
1 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) 2 D D 18 0 0
Lender s N ime
Lender s Address
I certify that I have read this application and state that the 0929-80
above information IS correct I agree to comply with all Courty
ordinances and State laws regulating Plumbing and Sewers
and hereby authorize representatives of this County to enter
upon the above mentioned pro erty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Slgnat of Per ittee Date
Y