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HomeMy Public PortalAbout5017 BALDWIN AVE_Swimming Pool__ (2) WORKERS'COMPENSATION DECLARATION I hereby affirm that I have 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.) 76A20B Policy No.�Company a 4L1 CE876(3/84) COUNTY OF LOS ANGELES. BUILDING AND SAFETY Certified copy is hereby furnished. BUILDIN FOR APPLICANT TO FILL IN G Certified copy is filed with the county building inspec- ADDRESS !rl r��yl��Yh dJe- tion department. BUILDING ��y� Q , a _ //..��,.r / ADDRESS J" I�LR��u�'n 1/pr s LOCALITY / Date Applicant e0`-9C1 6 �^ NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CITY _!�C_ tr,,�' ZIP /. �(� CROSS ST.SORpo['Lt)D Gj t/l a COMPENSATION INSURANCE TRACT LOT F LOT NO. MAP ASSESBOOK 4 a / PAGE PARCEL (This section need not be completed if the permit is for one TEL. USE ZONE MAP hundred dollars (;100)or less.) OWNER �YI 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 ay.e CONDITIONS so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY CITY fj n ZIP / CONST. Date Applicant ARCHITECT OR TEL. J/ CLASS NO.6, NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER ' , ( g N �� �0 Exemption, you should become subject to the Workers' VALUATION Compensation provisions of the Labor Code, you must forth- ADDRESS J[ 0� C/A 51� b c� VALIDATION with comply with such provisions or this permit shall be TEL T pt $ /l© GJQ©, deemed revoked. CONTRACTOR /r e G= NO O 1�f LICENSED CONTRACTORS DECLARATION rr j LIC. ADDRESS �-O Cr' Val fi �j L)� NO. I hereby affirm that I am licensed under provisions of Chapter 9 LIC. ; (commencing with Section 7000) of Division 3 of the Business CITY LIT CLASS [-v 6-T3 and Professions Code, andmylicense is in full force and effect. DESCRIPTION OF WORK License Number 1 � � Lic. Class 8), s� SWI IINGG PO�/g� �/ a DA EL (0 G! / � BScii �� SPA FINAL Contractor j u Date SQ. FT. BY I am exempt under Sec. SIZE O B.&P.C. for this reason ELECTRICAL Date: O Signature Steel &Conduit Bonding 9 Conduits, Conductors, Equipment W SINGLE FAMILY CL HOME OWNER-BUILDER DECLARATION PLUMBING W I hereby affirm that I am exempt from the Contractor's License f,_,_ — Law for the following reason (Section 7031.5, Business and P-Trap _ Professions Code): Gas System , ,,r••, I, as owner of the property, will do the plumbing and Anti-Syphon _t y ,k electrical work. I,or my employees with wages as their r _ sole compensation,or a licensed contractor will do all MECHANICAL other work and the structure is riot intended or offered I -t for sale (Section 7044 B&P Code). Swimming Pool Heater E413 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for APPLICANT TEL. 7 EN+= � _ the performance of the work for which this permit is issued (PRINT) a � � NO..( TOTAL a g (Sec. 3097, Civ. C.). tt ,� O I AL "� - V - a9s�:, Lender's Name ADDRESS ->-�1JT V i3wj Milo C rl""•Ir: _9 1.93 Lender's Address G� �� y/; '�C?Yii'= .00 LinCv�' Fee$ �/14 Permit Fee 0 �(/ I certify that I have read this application and state that the above information is correct. I agree to comply with all County �/- r/� - ordinances and State laws relating to building, electrical, Issuance Fee ry u (JUUHL;-(.i:`ui }./,j:`7/9-5 mechanical and plumbing construction, and hereby authorize stigation Fee __ _ '- (-IN# representatives of this County to enter upon the above- Total Fee D l i / ✓ i1 _5 11'.`1 mentid property for inspection purposes. Knot r of Appl'c t or A Date SEE REVERSE FOR EXPLANATORY LANGUAGE