HomeMy Public PortalAbout5227 AGNES AVE_Swimming Pool_5/26/1988 .?ENS.ATION DECLARATION
'I Wade a certificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT .
state of Workers' Compensation Insurance,
y thereof (Sec. 3800, Lob.
/C/))/� 76A20B
„A11i�'Company 4/W�( CE876(3184) COUNTY OF LOS ANGELES BUILDING AND SAFETY
A copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING ^�a
ed copy is filed with the county building inspec- ADDRESS ,�
epartment. BUILDING 452-7-1
j
yQ ADDRESS 1r ,0� r LOCALITY
Applicant NEAREST
::ERTIFICATE OF EXEMPTION FROM WORKERS' CITY ZIP CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO. .MAP BOOK PAGE PARCEL
vection need not be completed if the permit is for one TUSE PE MAP
-ed dollars ($100)or.less.) OWNER NOfi NO.
tify that in the performance of the work:for which this SPECIAL
'mit is issued, I shall not employ any person in any manner ADDRESS Ve CONDITIONS
.has to become subject to the Workers'Compensation Laws. DISTRI(-T I STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIPCLA55 Np, CONST. �/1�/A
fi;�;te Applicant ARCHITECT OR TEL. /�}
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. LJI
ExtSmption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS
Witt) comply with such provisions or this permit shall be ] TEL. $ fl }10 VALIDATION
'i deemed revoked. CONTRACTOR -/ NO. fi UV
LICENSED CONTRACTORS DECLARATION ✓ UC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �j• LIC.C. $
(commencing with Section 7000) of Division 3 of the Business
CITY e___7 �� . CLASS
and Professions Code; and my license is in full force and effect. DESCRIPTION OF'WORK `
FINAL/
license Number O� LicZToss_� SWIMMING POOL DATE
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CLSCO SPA
Q
Cotrator Date
SQ. FL
El I am exempt under Sec. SIZE 4 -9 9,7 O 7 R tx
B.BP.C. for this reason ELECTRICAL ��` 0. , ` o 0 o 10 21 U'
ate: r a
Signature Steel 8 Conduit Bondingu). /
g Conduits, Conductors, Equipment. 0 �' `� �'
S
GE AMILY Z
HOME WNER-BUILDER DECLARATION PLUMBING ° o .I O 1.'5 3 v
I hereby affirm th t I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and poll. 0 S 2 6-8 8
G
j Professions Code): as S
Gas System t�Y
I, as owner of the property, will do the plumbing and Anti-Syphon , Liar
electrical work.1, or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL �9 7 0 8 a
other work and the structure isnot intended or offered
for"sale (Section 7044 B&P Code). Swimming Pool Heater P0,0 0 0 0 3
CONSTRUCTION LENDING AGENCY 3 5 1 / b
L hereby affirm that there is a construction lending agency for I`
APPLICANT
'the performance of the work for which this permit is issued (PRINT)dbOtPAU/ o o z 3 �.%:fj s
(Sec. 3097;'Civ. C.), `' v'
Lender's Name ADDRESS
Lender's Address
• - t �• 1 �� Permit Fee
I"certify that i have read this application and state that tP.C. Fee$he /0 `,y
i above information is correct. I agree to comply with all County 1 (f
ordinances and State laws relating to building, electrical, Issuance Fee
'r mechanical and plumbing construction,-and hereby authorize Investigation Fee / -
representatives of this County to enter upon the above- Total Fee3,5 / t?
mentioned prop �fo inspection purposes.
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nat_re o Applicant or Agent Date SEE REVERSE iFOR EXPLANATORY LANGUAGE