HomeMy Public PortalAbout6003 AVON AVE_Swimming Pool_7/22/1985_ i
WOPKERS•'COMPtWSATION DECLARATION 2. R��/��p n(� y� n�( (�.�(/ ❑(�❑(� (�p/� p n�(� y�
I sure, o a cer that I have certificate of consent to self /�(�np �(r'hI�OO�I I!-O� �VI1GlIL��IIVQ II �OI1V JVV�IIlNI1VIl�UVI�J POOLS P�1t�11V11�11
insure, or a certificate of Workers' Com ensation Insurance, /n11rP CA
or a certified copy thereof (Sec. 3800, Lab. C.) 76A20B
CE-875(11/81)
Policy No.—Company - COUNTY OF LOS ANGELES' BUILDING AND SAFETY
aCertified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with.the county building insect- � ADDRESS QGrJ `
tion department., BUILDING
ADDRESS. QN LOCALITY .
Dote_7-19^1K!E Applicant v NEAREST
CERTIFICATE OF EXEMPTION FROM RKERS' CITY �/�jl� ZIP _ Q
LOT LOT NO. MAP BOOK PAGE 7PARCELCROSS 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 oneTEL.
NO.
I certify that,in the performance of the work for which this yy����--•� - SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS C� GJ�-�� �Vt3N r CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY CLASS NO. CONST.
Date Applicant ARCHITECT OR TEL. 542 �+
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER .�� S NO.(7 ey �/1
Exemption, you should become subject to the Workers' _ VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS.1=22 C/4Cl VALIDATION
with comply with such provisions or this permit shall beTEL $ /,(/�
deemed revoked. CONTRACTOR ,4/(J NO.4&1J--6:&3e r
LICENSED CONTRACTORS DECLARATION -�/� LIC. -Z:/
ADDRESS-<
I hereby affirm that I am licensed under provisions of Chapter 9 $
(commencing with Section 7000 of Division 3 of the Business LIC'
( g ) CITY GA�✓� ��4 • /�+al�CLASS C—S-3 • �'
and Professions Code,
,aaan�d-m(yy license is in full force and effect.
DESCRIPTION OF WORK �
�TJ T-7 Lic.•Class S3 t Imo^ FINAL ,rj V
License Numyb�er �g SWIMMING POOL /� DATE (�jf �@C
Contractor,//� ����GS DateSPA FINAL ;F.
SO. FT. 1 BY
EJI am exempt under Sec. SIZE H
! �C. �2-S X250. W
B.&P.C. for this reason ELECTRICAL #,o 0 0 0
t •
Date:
Signature
Steel &Conduit Bonding
f Conduits, Conductors, Equipment '( °•° x
SINGLE FAMILY '0 0 0 ��
HOME OWNER-BUILDER DECLARATION PLUMBING
1 hereby affirm that I am exempt from the Contractor's License i Y D 07.22-85
Law for the following reason (Section 7031.5, Business and I 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 z 2 5 0.7 A
sole compensation,or a licensed contractor will do all MECHANICAL
other work and-'the structure is not intended or offered #.o. 0 0 0 a
for sale (Section 7044 B&P Code). + Swimming Pool Heater l
CONSTRUCTION LENDING AGENCY /) °.1 4 3,63
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) j°-/l`r �LSNO.Cj D
(Sec. 3097, Civ. C.).
r _
Lender's Name /ADDRESS % S `� A/ ADIA ° ° 1 4 3 6 3 v
Lender's AddressA ,j
/ ! P.C. Fee.$ 11 Permit Fee 35 ' 13
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, I Issuance Fee. oiJ V
mechanical and plumbing construction, and hereby authorize Investigation Fee
representatives of this County to enter upon the 'above- Total Fee
;�x
Wpery for�' ection purposes.
2-( 8 -��
Signature of Applicant 0OAgent Date SEE REVERSE FOR EXPLANATORY LANGUAGE