HomeMy Public PortalAbout5750 ALESSANDRO AVE_Swimming Pool__ COMPENSATION,rECLARATION
her �• ,, r that I have a corrCome'of consent to Self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure,, g or a certificate of Wooers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.) 76A20B
CE876(3/84)
Policy No. ;N� Cc mpanY COUNTY OF LOS ANGELES BUILDING AND SAFETY .
Certified.`aPY is hereby furnished. -
�/ -FOR APPLICANT TO FILL IN BUILDING
9%
ified copy is filed with the c ty building inspec- � ADDRESSnon departnf. BUILDING
��,, ADDRESS t�o^ LOCALITY
Date pplicant ,C�L�1f
_ NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY.- ZIP 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. USE ZONE MAP .
hundred dollars($100)or less.) OWNER LN (� 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
so as to become subject to the Workers'Compensation Laws. DISTRICT ATATISTICAL CLASS TYPE PROCESSED BY
CITY
ZIP CO
Date Applicant ARCHITECT OR TEL /� �) CLASS NO. �^
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER /L' N .
Exemption, you should become subject to the Workers— VALUATION u
Compensation provisions of the Labor Code, you must forth- ADDRESS VALIDATION
with comply with such provisions or this permit shall be - $
deemed revoked. CONTRACTOR NOff'/ Q
.LICENSED CONTRACTORS DECLARATION LIC. r 2 8 6 Q2 A
ADDRESSNO. 0 0 0 0 2;1
1 hereby affirm that I am licensed under provisions of Chapter 9 �* $
(commencing with Section 7000) of Division 3 of the Business LIC.
and Professions Code,and my 'ce7c.
' in full force and effect. CITY CLASS C- 3 ( o o $(( ]9
DESC PTI OF WORK
License Numb Class FINAL ® o ° o iI r7 9
Q
SWIMMING POOL DATE — �
OLSJ / I i—Q SPA �//�/ I F 1215-87
O
Contracto Date (�
SQ. FT. � !/
Elam exempt under Sec. SIZE a
B.&P.C. for this reason ELECTRICAL zr 8 6 0.3
Date:
o 0 0 0
Steel &Conduit Bonding 0
W
1 ° 2 9 5, 5 0 0.'
Signature Conduits, Conductors, Equipment M N
SINGLE FAMILY - 29a506
Z
HOME OWNER-BUILDER DECLARATION PLUMBING ® C 2 15-87
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and P-Trap
Professions Code): Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I, or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TEL.
the performance of the work for which this permit is issued (PRINT) NO,
(Sec. 3097, Civ. C:).
Lender's Name ADDRESS',
Lender's Ad ress ✓// (c� i/yJ�
_ P.C. Fee$ / Permit Fee•
I certify that have r ad this a plication and state that the
above informa'on is torr ct. agree to comply with all County -
ordinance nd tate s relating to building, electrical, Issuance Fee
mechan' al and p mb' 9 construction, and hereby authorize Investigation Fee /
re Motives of County to enter upon the above- Total Fee r_S
lone ert r ' s e ion purposes.
Sig ature of hplslieew�s Date SEE REVERSE FOR EXPLANATORY LANGUAGE