HomeMy Public PortalAbout6242 AVON AVE_Swimming Pool__ { W,00KERS'C6' PENAi•ATION 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
876(3/84)
Po icy Company Cl'?�►-��Ti U f�3 � COUNTY OF LOS ANGELES' BUILDING AND SAFETY
❑ Certified copy is hereby furnished. L—�' —r v
�-�,,�^ 1 BUILDING
FOR APPLICANT TO FILL IN y� �c
I� certified copy is filed with the ty building inspec- ADDRESS �p�� /�< V
`P'�tionepariBUILDING / `
t� X ADDRESS (�i `4 LOCALITY F--4
Date +J A plicant� -{-- NEAREST
CERTIFICATE OF EXEMPTION FROM WORKE CITY, � y' ZIP CROSS ST.
COMPENSATION INSURANCE /h�`� ~SIZE OF ASSESSOR
TRACT , �V / LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for onen � TEp. USE ZONE MAP
hundred dollars ($100)or less.) OWNER B2W d LU1 (k � s- NO.
�KD
I certify that in the performance of the work for which this �jq �.J �' SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS 2-4� /� C �J� CONDITIONS
.so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY L ZIP D CONST.
Date Applicant ARCHITECT.,QB.. TEL. /I f`'� CLASS NO. �
ENGINEER L �S NO.& k'[_
NOTICE TO APPLICANT: If, after making this Certificate of ` y `
Exemption, you should become subject to the Workers' ADDRESS�� Q � �'\ 'NJ VALUATION
Compensation provisions of the Labor Code, you must forth- [� [fir VALIDATION
with comply with such provisions or this permit shall be CONTRACT 1J `f' `�5 .NO. CL(06S
$ 1 aoG
deemed revoked.
LICENSED CONTRACTORS DECLARATIONADDRESS CIU
�� ���•y� LIC.NO. `'
-'t
I hereby affirm that I am licensed under provisions of Chapter 9 LIC. $
,(commencing with Section 7000) of Division 3 of the Business CITY v( CLASS J3 v
and Professions Code, and my license is in full force and effect. z 7 6 A
DESCRIPTION OF WORK #
o 0 0 0
A�NS-W- l\ FINAL 1r
License Number \ Lic. Class SWIMMING POOL DATE ~v
� � { _q SPA
D � .a 06805=
/M
Contracto/� 1�� �A� GLS ate O�1 SPA aK�'�W U / FINAL a o0 0 �{j,
t_Jy`' SIZE n�C/ BY 0 c7 r� J U00
SQ. FT.
❑ I am exempt under Sec. s`� v` C
B.&P.C_ for this reason ELECTRICAL I`1?� # a`'� 6,6
Date: Nil #,o'z 7 6o o ego
�
Si Ll.l
nature Steel &Conduit Bonding
9 Conduits, Conductors, Equipment �('o 2 3 9 096 Z
SINGLE FAMILY 0 0 2 3 9 @f-
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License ► O 8 1 3,-8 7
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 7
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater # a o e o
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT
TEI��
the performance of the work for which this permit is issued (PRINT) �r•` N0={"'Ge���J
(Sec. 3097, Civ. C. ((��
Lender's Name b ADDRESPI(-e U
Lender's Address //�
P.C. Fee$ r(/ Permit Fee >
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County O ,
ordinances and State laws relating to building, electrical,' Issuance Fee
mec nica d pl mbing construction, and hereby authorize Investigation Fee
rep esentative o this County to enter upon t e above- Total Fee
me ion d per y nspection purpose
Sig azure of Applicant or gen Date SEE REVERSE FOR EXPLANATORY LANGUAGE