HomeMy Public PortalAbout5746 AGNES AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I havecertificate of consent to self APPLICATION FOR COMBINATION SUVtiillMING POOL PERMIT
insure, arra certificate of Workers' Compensation Insurance,
ora er ified copy the f Sec. 3800, Lab. C.) 76A20B
��j �'��"i �-�� ��� CE876(3/84)
Polic�t �Company� Q COUNTY OF LOS ANGELES BUILDING AND SAFETY
rCertified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspec- ADDRESS ((
tion department. BUILDING 7,q _ A� °�
ADDRESS / `T(J/ C� / LOCALITY
Date 4-q te Applica a, e F- NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY w ZIP 50 CROSS ST.
SIZE OF ASSESSOR
COMPENSATION INSURANCE �/�7
TRACT LOT LOT NO. MAPBOOK O PAGE��� PARCELG�/
(This section need not be completed if the permit is for one TEL. ] -& USE ZONE MAP
hundred dollars ($100)or less.) [ADDRESS
ER �/ NO�..C1i NO.
I certify that in the performance of the work for which this A ' SPECIAL
permit is issued, I shall not employ any person in any manner � Av� CONDITIONS
so as to become subject to the Workers'Compensation Laws. .'moi DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY 'f�" ' ZIP
Date A licant ARCHITECT OR TEL. CLASS,NO. / CONST.
NOTICE TO APPLICANT:pf, 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 ��j,J _ I, n
/ VALIDATION
with comply with such provisions or this permit shall be CONTRACTORr�/ �✓` D t/� NO. � $ I����/ la
deemed revoked.
LICENSED CONTRACTORS DECLARATION ADDRESS --
I hereby affirm that I am licensed under provisions of Chapter 9 LIC. $
(commencing with Section 7000) of Division 3 of the Business CITY / CLASS r 5!) -.-• R
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK W` ' °F
1 !J ¢�� FINAL _
License Number 7 Lic. Closs(�•/�-J K3 j— e
Q.f SWIMMING POOL
ede ,2& 719 FINAL ' , itF }
Controctc�-e •✓� ate � SPA V Ail-- ^
SQ FT.
I am exempt under Sec. SIZE BY }
O
B.&P.C. for this reason ELECTRICAL
aL
Date: O- {' �=
Steel &Conduit Bonding - s
Signature Conduits, Conductors, Equipment Lt!
SINGLE FAMILY �C :' _tos"I :a-
HOME OWNER-BUILDER DECLARATION PLUMBING
•HECK
I hereby affirm that I am exempt from the Contractor's License Poo
Law for the following reason (Section 7031.5, Business and P-Trap
Professions Code): Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon Mr
;j; =1s,""._ ='r '• ';-: ;:c
electrical work. I, or my employees with wages as their ) M 7?
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./, �'6;� ✓
the performance of the work for which this permit is issued (PRINT).' NO.
(Sec. 3097, Civ. C.).
Lender's Name �'
ADDRESSftrJ 4 e- ✓` r
Lende'"s Address ///1 /� ` 02
P.C. Fee$ / Permit Fee gee
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinar)ces and State laws relating to building, electrical, Issuance Fee 4
mechanical and plumbing construction, and hereby authorize Investigation Fee
representatives o this County to enter upon the above- Total Fee (O /
ZMted propert for inspection purposes.
72 -6075;
!"$gnature of pp Ko v e-nt Date SEE REVERSE FOR EXPLANATORY LANGUAGE