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Home My Public Portal About5837 AGNES AVE_Swimming Pool_6/26/1989_ �+ VoJ)PKERS COMPENSATION DECI ARATION I herpty a{wm that I have 6 certif ale of consent to self nsure i or a certificate of Workers Lompensation Insurance a APPLICATION FOR COMBINATION SWIMMING POOL PERMIT or a cert;he`d copy thereof (Sec 3800 Lab C ) 76A206 - r cE876 c3/841 Policy No r - �� Company COUNTY OF LOS ANGELES BUILDING SAND SAFETY Certified copy is hereby furnished FOR APPLICANT TO FILL IN _ BUILDING Certified copy is filed with the county building inspec ADDRESS L- tion departmentBUILDING ADDRESS 36II&W 1 'S LOCALITY Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS CITY AL2` _ y ZIP `7 Dry Q CROSS ST COMPENSATION INSURANCE SIZE OF ASSESSOR TRACT LOT LOT NO MAP BOOK PAGE PARCEL (This section need not be completed If the permit is for one TEL VDIS;TRICT , MAPS hundred dollars ($100)or less ) OWNER Z� Lf &. NO NO I certify that in the performance of the work for which this SPECIAL permit is issued I shall not employ any person in any manner ADDRESS [� CONDITIONS y 4 so as to become subject to the Work rs Compensation Laws STATISTICAL CLASS TYPE PROCESSED BY CITY 7�E ZIP !!' �O CLASS NOCONSDate v Applica ARCHITECT OR ` TEL+NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO 31 Exemption you should become subject to the Workers VALUATION Compensation provisions of the Labor Code you must forth ADDRESS ,GSC/ `' v with comply with such provisions or this permit shall be TEL $ 7 �— VALIDATION deemed revoked CONTRACTOR �iC/��L NO LICENSED CONTRACTORS DECLARATION _ LIC I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO LIC ; (commencing with Section 7000) of Division 3 of the Business CITY " CLASS and Professions Code and my license is in full force and effect DESCRIPTION OF WORK _ FINAL n <_ License Number Lic Class SWIMMING POOL DA,712:-1 Contractor Date SPA FINA QSQ FT J / BY � r V I am exempt under Sec SIZE (� B &P C for this reasono ELECTRICAL 4Y Datea a a Steel 8 Conduit Bonding TM Signature SINGLE FAMILY Conduits Conductors Equipment _ Z HOME OWNER BUILDER DECLARATION PLUMBING ' I hereby affirm that I am exempt from the Contractor s License 3 Law for the following reason (Section 7031 5 Business and P Trap ` Professions Code) Gas Sy stem ACC7.4 I as owner of the property will do the plumbing and Anti Syphon � � � � electrical work I or my employees with wages as their sole compensation or a licensed contractor will do all MECHANICAL other work and the structure is not intended or offered _ 23 for sale (Section 7044 B&P Code) ~ Swimming Pool Heater ( CCT.8 +r CONSTRUCTION LENDING AGENCY 4 J7 eco 1(t I hereby affirm that there is a construction lending agency for APPLICANT TEL T the performance of the work for which this permit is issued (PRINT)�' — fC NO 6 ® 2 1TEME Civ 3097 v C ) Lender s Name ' ADDRESS 7 �} S G� GJ T;y�`T � 0 Lender s AddressC HECK 141t.*CI P C Fee S Permit Fee a ('L� I certify that I have read this application and state that the CHAP o` i above information is correct I agreeRo comply with all County ordinancesand State laws relating to building electrical Issuance Fee _ mechanical and plumbing construction and hereby authorize Investigation Fee � _ i �'.yb,V� representatives of this County to enter upon the above Total Fee �0 1 ML ment oned prope�forspection purposes 4179 1 All 9:18 Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE