HomeMy Public PortalAbout4941 ALESSANDRO AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self � APPLIC$7I0N FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers' Compensation Insurance, •�:, u
or.a certified cod/y thereo ec. 3800, L�a1b. C!) v 76AzaBB W'
o� � �J-iy�/' �r/ CE876(3/84)
Policy N . o pang —� COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certi ted copy is hereby furnished.
FO0 APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspec- ADDRESS
tion department. BUILDING
ADDRESSLOCALITY
Dat Applicant AV
NEAREST
750
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY ?' ZIP CROSS ST.
Plez COMPENSATION INSURANCE SIZE OF ASSESSOR /
TRACT LOT LOT NO. MAP BOOK o PAGE e5:1261 PARCEL'f�'J f�
(This section need not be completed if the,permit is for one TEL. USE ZONE MAP
hundred dollars($100)or less.) OWNER NO, NO.
I certify that in the performance of the work for which this =�p /� SPECIAL `
permit is issued, I shall not employ any person in any manner ADDRESS �-� 1/+' CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CONST.
Date Applicant ARCHITECT OR TEL. j1 CLASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. J-0
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be TEL. /�n I VALIDATION
deemed revoked. CONTRALTO NO� s
LICENSED CONTRACTORS DECLARATION C.
ADDRESS
ADDRESS O.
hereby affirm that I am licensed under provisions of Chapter 9 LIC. $
(commencing with Section 7000) of Division 3 of the Business CITY 4,5W CLASS
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
//''_�'� FINAL ►
License Number
� � Lic. Class4� SWIMMING POOL l� DATE r •
ControctoF�-�t'��F_Ry'"-•? Date SPA SO. FT. p�(c�D 70 FI AL O.,
I am exempt under Sec. SIZE O
❑
B.BP.C. for this reason ELECTRICAL O
Date: F-
Steel &Conduit Bonding U
Signature Conduits, Conductors, EquipmentE5— W
SINGLE FAMILY d
HOME OWNER-BUILDER DECLARATION PLUMBING "?
I hereby affirm that I am exempt from the Contractor's License
j Law for the following rea son (Section 7031.5, Business and P-Trop
Professions Code): Gas System _-�-_
I, as owner of the property, will do the plumbing and Anti-Syphon =}.,�:_p.-;
electrical work. 1, or my employees with wages as their 3
sole compensation,or a licensed contractor will do all MECHANICAL -
other work and the structure is not intended or offered Ar-CT.'
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 1{E3(:;
I i
the performance of the work for which'this permit is issued PRINT NO.
(Sec. 3097, Civ. C.). €ti¢iss „
IL
Lender's Name ADDRES 7 6 VI r4E"
x
Lender's Address "�/�
P.C. Fee$ Permit Fee
1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County
Issuance Fee
ordinances and State laws relating to building, electrical, �• � 6 i ilf• �'sf=sl rli jti��,
mechanical and plumbing construction, and hereby out
Investigation Fee O /
representatives of this County to enter upon the above- Total Fee �j , _; " - y 1 q4%
mentioned pr rt for inspection purposes.
c _
/Signaturdf of A i ant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE