HomeMy Public PortalAbout4949 AGNES AVE_Swimming Pool_2/8/1988_ t t�q �RKER9i COMPENSATION DECLARATION
insureby ff e, fact I have a certificate ns cion Inca self k APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure or a cettrficate of Workers Compensation Insurance 1
of a Pr i e0_,*py th reof (Sec 3800 Lab 'C ) 4 a 76A20B
u cy n/�(, 'V _ (� CE676(3/84)
Policy N,o A ��4�"CC Company T r""��`�-�LCOUNTY OF IOS,.ANGELES BUILDING AND SAFETY
Certi�,ed copy is hereby furnished r T
" ' 4 A(9�
Certified copy is filed with the county building mspec FOR APPLICANT TO FILL IN w ` ADDRESS )'
`"T' tion department d BUILDING ,f k� 1 I�� T
gyp/ t e ADDRESS "S fy LOCALITY f
Date S' W ApplicantT NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS CITY l ZIP CROSS 5T ,
COMPENSATION INSURANCE ISIZEOFJ ASSESSOR
TRACT LOT LOT NO , MAP BOOK PAGE, PARCEL
(This section need not be completed if the permit is for one TELt USE ONE MAP r !
hundred dollars($100)or less ) C OWNER NO c.p " 6 IS NO
I certify that in the performancenof the work for which this A f SPECIAL /
permit is issued I shall not employ any persodin any manner ADDRESS S A CONDITIONS a
so as to become subject to the Workers Compensation Laws DISTRICT ATISTICAL CLASS TYPE, PR ESSED BY
( CITY ZIP CONST
Date Applicant ARCHITECT OR TEL G, CLASS NO
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO J s 5
Exemption you should become subject to the Workers v VALUATION 2 E
Compensation provisions of the Labor Code you must forth ADDRESS °
with complyewith such provisions or this permit shall be + TEL $ ODO VALIDATION
deemed revoked CONTRACTOR $ NO 78S'u 4
LICENSED CONTRACTORS DECLARATION LIC
� ADDRESS< TVNQ�S NO $SkOZ ..
I hereby affirm that I am licensed under provisions of Chapter 9 LIC = f
(commencing'withSection 7000) of Division 3 of tFie Business CITYCLASS" fv�s3
and Professions Code and my license is in full force and effect
mac- h, DESCRIPTION OF WORK FINAL n
LicenseiNumber 1 VJ�dZr Lic Class C ` SWIMMING POOL ® DATE �8 9 2 6✓n
Z ,�tN ® FINAL c # o • •�0 211
Contracto Date SPA 7
F-1 } SQ FT - DO LiZZ� By - I ° - 9595 W a
I am exempt under Seca I SIZE hJ�J
B 8P C for this reason ° ELECTRICAL - ° ° ° 9^5 9 5 0'
Date
Signature Steel & Conduit Bonding lI A n ` 0 2 0 8-8 8 N
' Conduits Conductors Equipment V UII ' Zr
SINGLE FAMILY r "
HOME OWNER BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor s License _ ,
Law for the following reason d(Section 7031 5 Business and P Trap Y 8 9 2 7 A
Professions Code) Gas System '
w �+
I as owner of the propertywill do the plumbing and Anti Syphon #! • e" o • 0 3
electrical work I or my employees with wages as their ry _
sole compensation,or a licensed contractor will do all MECHANICAL I ° 333 0 0
other work and the structure is not intended or offered _ b
for sale (Section 7044 B&P Code) Swimming Pool Heater N n
J ° ° 33300
� CONSTRUCTION�ENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TEL 2 .$--88
the performance of the work for which this permit is issued (PRINT) pjy�/y_� NO I pop 0
(Sec 3097 Civ C )
Lender s Name ADDRESS e—G l lU►'l S _
i
S r
Lender s Address c � ,.
PC Fee$ '5" Permit Fee
I certify that I have read this application and state that the r
above information is correct I agree to comply with all County -
ordinances and State laws relating to building electrical Issuance Fee 0,7—(Q
mechanical d plum ing construction and hereby authorize Investigation Fee r
represent es of County to enter upon the above Total Fee
a
mentione prope y r inspection purposes y
n
Sign re of Applicant or Agent ate SEE REVERSE FOR EXPLANATORY LANGUAGE' Y