HomeMy Public PortalAbout4848 ALESSANDRO AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I havecertificate of consent to Self APPLICATION FOR COMBINATION-SWIMMING POOL PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a ertified Copy thereof (lec.,3800, Lab. C. 76A20B
P y f20M_ �&n CE876(3/84) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polic o. C man ��T f f'
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING Q J �G �I
FT"Certified copy is filed with the county building inspec- ADDRESS
tion department. BUILDING
ADDRES 11LOCALITY C
Date '�/ App Iica �A /� NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY /�/, G(� ` ZIP ql D CROSS ST.
SIZE OF ASSESSOR
COMPENSATION INSURANCE TRACT LOT LOT NO. MAP BOOK l� PAGE �• PARCEL W J
(This section need not be completed if the permit is For one TEL. USE ZONE P
hundred dollars ($100)or less.) OWNER 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 CL f
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CLASS NO. NST.
Date Applicant ARCHITECT OR TEL. n� j
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER N
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS
T L.
G�L1 � VALIDATION
with comply with such provisions or this permit shall be $
deemed revoked. CONTRACTOR i O
LICENSED CONTRACTORS DECLARATIONU
ADDRES !/v O. ✓`
I hereby affirm that I am licensed under provisions of Chapter 9 x � LIC $
(commencing with Section 7000) of Division 3 of the Business CITY/t/ — CLASSI �-
and Professions Code, and my license is in full force and effect. DESCRIPTION OF WORK
l�!l FINAL
License Number �/ Lic. Class�� SWIMMING POOL DATE �!�J� �1 •
Contract&11� Date Q SPA U FINA
SQ. FT. BY 0,99 d
1 am exempt under Sec. SIZE 0
B.&P.C. for this reason ELECTRICAL
Date: 0
Si nature Steel &Conduit Bonding '6"!p / D f-
9 Conduits, Conductors, Equipment �1 �L W
SINGLE FAMILY tl
HOME OWNER-BUILDER DECLARATION e;s $
PLUMBING f-I:.•,.I='c
I hereby affirm that I am exempt from the Contractor's License. _, z
:
Law for the following reason (Section 7031.5, Business and ='!a '= °(='t
Professions Code): P-Trap
Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I, or my employees with wages as their tl l:1 ,ir
sole compensation,or a licensed contractor will do all MECHANICAL -3`0
�
other work and the structure is not intended or offered _'I., =i.h,~'
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY i€t-110
1 hereby affirm that there is a construction lending agency for TOTAL ETAL 54-4 - �=°
APPLICANT �� TEL �p�-�,-� �'I f
the performance of the work for which this permit is issued PRIN p����
(Sec. 3097, Civ. C.). C_•IEC: _t-i 4°L'_'-
Lender's Name ADDRES � ! t /{ CHANGE °�5=t
Lender's Address f
P.C. Fee$ od-/3. Permit Fee
I certify that I have read this application and state that the 131101 0=1j1 fne.`iL
above infer,mation is correct. I agree to comply with all County 2 $40
Issuance Fee T�/ - t •+.
ordinances and State laws relating to building, electrical, ,z,_ti.8 1 At 11 :
mechanical and plumbing construction, and hereby authorize Investigation Fee / `
representatives f this County to enter upon the above- Total Fee (o
neo_pr, e ty or inspection purposes.
Signature f Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE