HomeMy Public PortalAbout5233 ALESSANDRO AVE_Swimming Pool_4/18/1985_pool WORKERS' COMPENSATION DECLARA`i ION r
I hereby affirm'that I have a certificate o; consent to self
insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or a certifie opy there-of (Sec. 3800, Lab. C.) 76A20B
Wt� _�wm CE-875(11/81)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the unty building inspec- ADDRESS
tion depart ent. BUILDING
Date ApplicantC*QA ADDRESS �Z �' 6Nes. LOCALITY NEAREST 7 y
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY r{� t� ZIP / �J$ C7 CROSS SL
COMPENSATION INSURANCE SIZE OF 1. ASSESSOR
TRACT LOT LOT NO: MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one. TEL. USE ZONE MAP
hundred dollars ($100)'or less.) OWNER j NO. NO.
I certify that in the performance of the work for which thisSPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS —5-2 3 ti ' �6tie-S CONDITIONS
so as to become subject to the Workers'Compensation Laws. i DISTRICT STATISTICAL CLASS TYPE ,. PROCESSED BY
CITY ZIP �TrO ro CONST:
Date Applicant ARCHITECT OR I f TEL. CLASS NO w
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be TEL. $ 0�') VALIDATION
deemed revoked. CONTRACTOR v NO.e_ ZZ�j
LICENSED CONTRACTORS DECLARATION 10,5 D2 ~�
1 her affirm that I am ADDRESS NO.licensed under provisions of Chapter 9 / �"�� $
(commencing with Section 7000) of Division 3 of the Business C7 LIC.CLASS
y.
and Professions Code, and my license is in full force and effect. CITY CLASS .# 1 4 7 A
DESCRIPTION OF WORK O
21License Number 0� S Lic. Class SWIMMING POOL
e-z—e'
srn� fL�� 1� (oSPA ,
Contracto Date J
1 .
I am exempt u er Sec. SIZEFT f o o o g Q 3 6 cjLai
1/1
B.&P.C. for this reason ELECTRICAL O 021 -85
Date: 4 8 A
Signature Steel & Conduit Bonding
Conduits,'Conductors, Equipment
SINGLE FAMILY �. 0 0 0 0 0 3
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License ' ( 0 3 1 3.2 6
Law for the following reason (Section 7031.5, Business and P-Trap -
Professions Code):
Gas System 0 0 3 3,2 6_
0
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I, or my employees with wages as their d 0,21 — 85
sole compensation,or a licensed contractor will do'all MECHANICAL
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code), Swimming Pool Heater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TEL.
the performance of the work for which this permit is issued (PRINT) NO. ,
(Sec: 3097, Civ. C.).
Lender's Name ADDRESS
Lender's Address M,3
P.C. Fee$ Permit Fee
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee V
mechanical and plumbing construction, and hereby authorize Investigation Fee 2
re re enta 'ves of this County to enter
upon the above- Total Fee ✓
ment n property for inspection purposes.
tIr, �Applic.., ,oAgent Date SEE REVERSE FOR EXPLANATORY LANGUAGE