HomeMy Public PortalAbout6323 AGNES AVE_Swimming Pool_7/29/1989_ G' SATION DECLARATION \
certificate of consent to self
orkers Compensation Insurance APPLICATION FOR COMBINATION SWIMMING .POOL PERMIT
c 3800 Lab C )
76A20B
/ w�IeU CE876(
3/84)
o ploI
COUNTY OF LOS ANGELES BUILDING AND SAFETY
C rtifled copy is hereby furnished
l � BUILDING
Mr3C rtified copy is filed with��}��iounty buildinginspec FOR APPLICANT TO FILL IN ADDRESS
krt t on de ortn Ant , ) BUILDING t p
-tel y� 7 \ ADDRESS �� tv ��+L-4 LOCALITY
Date) u Applicant NEAREST f
CITY ZIP r CROSS ST
CERTIFICATE OF EXEMPTION FROM WO S SIZE O ASSESSOR
COMPENSATION INSURANCE TRACT LOT LOT NO"7 MAP BOOK I - PAGE I PARCEL
(This section need not be completed if the permit Is for one - 7 TEL USE ZONE MAP
hundred dollars ($100)or less ) OWNER / NO NO
I certify that in the performance of the work for which this ^2 �� SPECIAL
permit is issued I shall not employ any person in any manner ADDRESS J CONDITIONS
so as to become subject to the Workers Compensation Laws` RQC LBY
DISTRICT STATISTICAL CLASS TYPE P
CITY ZIP 5,0CLASS CONST/
Date Applicant ARCHITECT OR TEL tV/
NOTICE TO APPLICANT If after making this Certificate of ENGINEER -T NO l(
Exemption you should become subject to the Workerst' VALUATION
Compensation provisions of the Labor Code you must forth ADDRESS VALIDATION
with comply with such provisions or this permit shall beCONTRACTQ } _ NQ $
,deemed revoked //�!! � Q
LICENSED CONTRACTORS DECLARATION ADDRESS'(u A�c�5l� NO y„�-�
1 hereby affirm that I am licensed under provLIC
isions of Chapter 9 LIC $
(commencing with Section 7000) of Division 3 of the Business CITY 11l {v ` CLASS G
and Professions Code and my license is in full force and effect DESCRIPTION OF WORK "
1 FINAL
License Number �f�-Ak Lic Clas '� SWIMMING ® DATE 7 5 7
A �cx�5 U
SPA -
as( ` # e o ° ° 2 �.
Contractor Date SO FT FINA 3 =
I am exempt under Sec SIZE Q BY/ Q 7 3 0'
O
B &P C for this reason ELECTRICAL ,
Date Lil
Signature Steel & Conduit Bonding # ;02a
9 Conduits Conductors Equipment N
SINGLE FAMILY ) ° 2 5 &0 0' z
HOME OWNER BUILDER DECLARATION PLUMBING ®` ° ° 5 1 0`
"
1 hereby affirm that I am exempt from the Contractor s License T 7 0-
Low
dLaw for the following reason (Section 7031 5 Business and p Trap
Professions Code) , Gas System Y
I as owner of the property will do the j Iumbing 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; I I `
for sale (Section 7044 B&P Code) Swimming Pool Heater �k}�
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that there is a construction lending agency for APP`ICAN I _ TEL
the performance of the work for which this permit is issued PRINT NO
(Sec 3097 Civ C ) � /!
Lenders Name ADDRESSI Co L Q
Lender s Address /f)
P C Fee$ 3l6 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 r EOO mechanical and plumbing construction and hereby authorize Investigation Fee,
repre fives of this County to enter upon the above Total Fee 2c
me boned _pert for mspecnon purposes _
Signature of Applic t o Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE '