HomeMy Public PortalAbout4905 BALDWIN AVE_Swimming Pool__ (2) •L_ WC/RKERS CCJMPENSATION DECLARATION
I hereby aff}m that ffhave a certificate of consent to self
insure or a certificate of Workers Compensation Insurance APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or a certified copy thereof (Sec 3800 Lab C ) 76A40B
CE 875(11/81)
Policy No Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished
FOR APPLICANT TO FILL IN ADDRESS � �c
Certified copy is filed with the county building inspec � ADDRESS
tion department BUILDING 1
Date ' Applicant ADDRESS IN1 LOCALITY
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS CITY — ZIP 9 - CROSS ST
COMPENSATION INSURANCE SIZE OF ASSESSOR
} LOT NO PAGE
(This section need not be completed if the permit is for one TRACT LOT MAP BOOK PARCEL,(� F � r NOL _, U�,ZNE MAP -1 �Ji1hundred dollars(1100)or less ) OWNER L 1 MA /` ` 11
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 L i1- CONDITIONS
so as to become subject to the Workers Compensation Laws ^ ti DISTR T STATISTICAL CLASS TYPE PROCES ED BY
CITY ZIP COt fST
Date Applicant ARCHITECT OR I _ TEL OK
CLASS NO n
NOTICE TO APPLICANT If after making this Certificate of ENGINEER U [\ O31 )
Exemption you should become subject to the Workers N VALUATION
Compensation provisions of the Labor Code you must forth ADDRESS
with comply with such provisions or this permit shall be TEL S �� - — ' VALIDATION
deemed revoked CONTRACTOR NO
LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO $
(commencing with Section 7000) of Division 3 of the Business LIC
CITY / CLASS 1 e
and Professions Code and my license is in full force and effect DESCRIPTION OF WORK 51 b FINAL
License Number Lic Class SWIMMING POOL 15- DAT
( , 99
Contractor Date SPA FIN ° ° 9 0,3 6 0
O SQ FT _ V
I am exempt under Sec SIZE 1 ° m ° 9 0.3 6 5 w
v CL
B &P C for this reason ELECTRICAL _ \ 04 2 3-8 5 Z
Date
Steel & Conduit Bonding _ _ ;2 1 9 1 0 A
Signature Conduits Conductors Equipment SINGLE FAMILY `� � # o 0 0 0 0 3
HOME OWNER BUILDER DECLARATION PLUMBING ) ° J �l 2 6
I hereby affirm that I am exempt from the Contractor s License , \
Law for the following reason (Section 7031 5 Business and 0 0 3 1 4 2 6
Professions Code) P TrapGas S stem n� 5 1
Y
I as owner of the property will do the plumbing and Anti Syphon ' 0 (L23-85
electrical work I or my employees with wages as their i
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 LENDINGAGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TEL i
( the performance of the work for which this permit is issued (PRINT) S NO 4114
(Sec 3097 Civ C )
Lender s Name ADDRESS ,
Lender s Address DA 3.
7•(?/
P C Fee Permit Fee I
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
mechanical and plumbing construction and hereby authorize Investigation Fee
representatives of this County to enter upon the above Total Fee
mentioned property for inspection purposes
CL Lf > 3
Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE