HomeMy Public PortalAbout4833, 4825AGNES AVE_Sewer (17) WORKERS COMI FNSATION DECLARATION 76A6420
CE 808 (2 80) APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL v/
Insure or a certificate of Workers Compensation In urance or
a certified copy thereof(Sec 3800 v COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No�/327/ Company '
Certified copy�is hereby furnished FOR APPLICANT TO ILL IN CONNECTION DATA
BUILDING ��� pT10N 25�4DEPTH
Certified copy Is filed with the unty builchng Inspection ADDRESS VVVV
apartment LOCALITY OLE REFERENG yy 6 �d OWER
Date0s Applicant NEAREST YPE OF CONNECTION LENGTH FROM �F
CERTIFICATE OF EXEMPTION FROM WORKERS cRoss sT Y CURB P L M L ro P L /
COMPENSATION INSURANCE _ O IMP NO JOB NO P C No �
OWNE C }
(This section need not be coni leted if the work involved ADDRESS Q/ / ` C'
MAIL P Q G�p � TRUNK PERMIT NO ROAD PERMIT NO O
by the permit is for one hundred dollars ($I00) or less) APF DAV 7 WAVER EA EMENT RECORD N TR NO DATE U
CIT ;^Vf EL NO 0�A�Z7
I 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
NWY OR ST WIDENING 0
so as to become subject to the Workers Compensation Laws U
BLOCK TRACT 7 STATE ENCROACHMENT (V
Date Applicant NO OFSLOGS PERMIT NO a
Z
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 CHARGES
Compensation provisions of the Labor Code BUILDINGS
p p you must forth
with comply with such provisions or this permit shall be � dam✓ y� CONNECTION CHARGE FEE
deemed revoked CONTRACTor,,:--
REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS �i
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 Bust STATE CITY TEL No BK G
ness and Professions Code and my license Is in full force and LICENSE NO „s CLASS `� ��
effect S `
(p NO DESCRIPTION OF WORK FEE
��
/ HOU E EWER CONNECT NG TO FINAL'
'1 SO� VALIDATION
License Number Lie Class � uB C EWER DATE d� ��/
^_ E T CT NK SEE AGE TOR
Contrac r 9
ate r �Z_ ill vl T AND/OR ORA NF E D FIN
HOUSE EWER CONNECT NG TO
0
R VATS D O A Y TEM
I am exempt from the licensing requirements as I am a CONNECT ADD T DNA B OG OR LI
licensed architect or a registered professional engineer WORK TO HOU E EWER
acting in my professional capacity (Section 7051 Bus OVERF OW SEE AGE T ORA NF E Dl
mess and Professions Code) EXTN CE oo DR we MANHo E
A TER REA R OR ABANDON HOU E
EWER OR D O A V TEM
Llc 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
nese and Professions Code) HAVE A THDATE A CONTRACT W TH THE HERE N NAMED CON
❑ RACTOR TO CONNECT THE ABOVE DE CR BED EX T NG OWE NG
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 —4--DAY OF r
7044 Business and Professions Code) OWNER OR :12330A
OWNER
CONSTRUCTION LI NDING AGENCY ADDRE
I hereby affirm that there is a construction lending agency # D o D D 1 0
for the performance of the work for which this permit is
Issued(Sec 3097 Civ C) 2 e D 1 a 0 0
Lender s Name
Lender s Address D o D 1 8,0053
1 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,*e above mentioned property for inspec on purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re of rmt a Date