HomeMy Public PortalAbout5752 AGNES AVE_Swimming Pool_4/7/1986_ WORKERS COMPENSATION DECLARATION �[
ifhreby ithat I have 17 certificate of consent to self APPLICATION ,FOR COMBINATION SWIMMING POOL PERMIT
i suus certificate or a cerhficata of Workers Compensation Insurance
or a certified copy thereof (Sec 3800 ab C 417176A20B `
G `� CE876(3/84)
Pol'c4y 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 c my buildm in ADDRESS J
tion department BUILDING ,(/s�
1/,9 `/ 0 ADDRESS .J/ LOCALITY
Date? Q k� Applicant (• NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS CITY ZIP CROSS ST
COMPENSATION INSURANCE SIZE F ``,, ASSESSOR
TRACT LOT LOT NO T� MAP BOOK t PAGE PARCEL
(This section need not be completed if a permit is for one TEL �j USE ZONE ~MAP
hundred dollars ($100)or less ) OWNER NO /�] NO
I certify that m the performan the for which this SPECIAL v
permit is issued I shall note I a erson in any manner ADDRESS CONDITIONS r
so as to become sublect to t e ers ompensation Laws r DISTRICT STATISTICAL CLASS TYPE PROCESS D BY
} CITY ZIP �^ DIY CLASS NO CO ST
Date A scant ARCHITECT OR TEL (J d
NOTICE TO APPLIC If after making this Certificate of ENGINEER NO
Exemption you ouId become sublect to the >Workers VALUATION
Compenso1 0 provisions of the Labor Code you must forth ADDRESS /(1 `= RJ D� VALIDATION
with com with such provisions or this permit shall be TEL /_� �_� $
deeme evoked CONTRACTOR NO
LICENSED CONTRACTORS DECLARATION ADDRESS _3023 NO LIC
f L 2(j
I hereby affirm that I am licensed under provisions of Chapter 9 M $
(commencing with Section 7000) of Division 3 of the Business LIC
CITY CLASS
and Professions Code and my license is in full force and effect - -
�U/4�4 n S� DESCRIPTION OF WORK FINAL
License Number Lic Class ( ' SWIMMING POOL O CJ DATE Z27 ® }
%n vq a
Contractor Date SQ AT' F L +1 4 3 fl 1A
El I am exempt under Sec SIZE tr o c • * 21
Q'
/ 0
B 8P C for this reason ELECTRICAL r , ( • - 6 a 0 5 U
Date o o • 6&2 5' a
Signature Steel 8 Conduct Bonding - s Q 0 7- 6
Conduits Conductors Equipment
SINGLE FAMILY ti
HOME OWNER BUILDE D TION PLUMBING
I hereby affirm that I am exemp r e Contractor s License
Law for the following reaso (Se wn j�31 5 Business and P Trop S k 4 3 8�2 A
Professions Code) /l/J Gas System r • • o • e
1 as owner of the operty will do the plumbing and Anti Syphon ` # `�
electrical work or my employees with wages as their 1 - 23926
solercompe tion or a licensed contractor will do all MECHANICAL Y "
other w and the structure is not intended or offered • - 23926'0-
for sale (Section 7044 B&P Code) Swimming Pool Heater
CONSTRUCTION LENDING AGENCY ` O i.0 7—8 6
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) *,fl— NO
(Sec 3097 Civ C ) "
Lender s Name ADDRESS
Lender s Address
PC 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 t
ordinances and State laws relating to building electrical Issuance Fee i
mechanical and plumbing construction and hereby authorize Investigation Fee T + `
epresentat of this County to enter upon the above Total Fee
1 .
ment e rop rty for inspection purposes
41— 749
Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE