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HomeMy Public PortalAbout6248 AVON AVE_Swimming Pool__ WORKERS COMPENSATION DECLARA,JION y, 1 hereby affirm that I have a certificate of consent tt self insure or a certificate of Workers Compensation Insurance APPLICATION FOR COMBINATION SWIMMING POOL PERMIT or a certifi d' copy thereo (Sec 3800 Lab C ) , 76A20B T (l}i1�3��G \ �,� _- ,. , ,� ) CE 875(11/81) y Policyicy o J ampany'' 1��' -ALJ COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished ' FOR APPLICANT TO FILL IN BUILDING Certified copy is filed with the county building mspec ADDRESS tion department BUILDING �_( 'sem ADDRESS LOCALITY Date 1TAIA JApplicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS C ZIP CROSS ST COMPENSATION INSURANCE SIZE OF ASSESSOR 00- TRACT LOT LOT NO MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one ♦ hundred dollars ($100) or less ) i TEL USE ZONE MAP OWNE \! NO NO C� 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 { ADDRES '/ CONDITIONS so as to become subject to the Workers Compensation Laws /DISTRICT STATISTICAL CLASS TYPE PROCESSED BY 1 CITY - ZIP CONST Date Applicant ARCHITEC -1 TE i CLASS NO NOTICE TO APPLICANT If after making this Certificate of s ENGINEER 1 Exemption you should become subject to the Workers i ADDREVALUATION _' Compensation provisions of the Labor Code you must forth '2� VALIDATION with comply with such provisions or this permit shall beT $ deemed revoked CONTRAC R LICENSED CONTRACTORS DECLARATION LIC ^1 I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS O // lam $ (commencing with Section 7000) of Division 3 of the Business LIC S�v-aJ >- and Professions Code and my lic nse is in full force and effect CITY CLA 0 ('\\ cC` DESCRIPTION OF WORK FINAL License Numbet�'1 U' I is Class w 3 SWIMMING POOL VN DATE r� U 09 o Contra&f,ai ate SPA FINAL I SO FTBY __x W I am exempt under Sec SIZE © IL 3 7 1 Ato B&P C for this reason Date z 1 Z ELECTRICAL r #'0 0 0 0 2 1 Signature Steel 8 Conduit Bonding " ' 21`0 o 84,79 SINGLE FAMILY Conduits Conductors Equipment HOME OWNER BUILDER DECLARATION PLUMBING o o e 8 4,7 q 0' I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 7031 5 Business and P Trap 0 k 2 1 —83 Professions Code) Gas System �� \ s 1 3 7 2 A I as owner of the property will do the plumbing and Anti Syphon electrical work I or my employees with wages as their �g #'a o e ot 0 3 sole compensation or a licensed contractor will do all MECHANICAL \p other work and the structure is not intended or offered l 1+t� 2 ° 1 5 300 for sale (Section 7044 B&P Code) Swimming Pool Heater Eyp CONSTRUCTION LENDING AGENCY ( 1 �� S° ° 1 5 3 0 0 c=a I hereby affirm that there is a construction lending agency for r� APPLICANT the performance of the work for which this permit is issued (PRINT) � N 6r� J&� 0 4,2 1 —8 3 (Sec 3097 Civ C ) t c- �� Lender s Nam �/ e ADDRESS-'/`�I 1 - ' I + Lender s Address - I certify that I have read this application and state that the P C Fee$ Permit Fee above information is correct I agree to comply with all County - ordinances and State laws relating to building electrical Issuance Fee r mechanical and plu g construction and hereby authorize Investigation Fee representat of this�urposes enter upon the above Total Fee , j mentioned pro ty fo Signatu a of Applicant r Agent {� Date SEE REVERSE FOR EXPLANATORY LANGUAGE \