HomeMy Public PortalAbout5941 AVON AVE_Swimming Pool_8/7/1990_ WOP 'W'COMPENSATION DECLARATION
I tby af:Lftm that I have a'certificate of consent to self
ns or a certificate of Woykers' Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or q y.rjified copy thereof (Sec. 3800,,71ob. C.) 6n20e
i►^ CE876(3/8a)
Policy N?t—Company-FPE� T COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. BUILDING
�ertified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS _5�9 4
tion department. BUILDING /f r�D / +/
ADDRESS /Qy LOCALITY
Date�_r.-9� Applicant / �i NEAREST \(\
CITY//:>d' L el ZIP 1W6 CROSS
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SIZE ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one TE USE ZONE MAP �-
hundred dollars($100)or less.) OWNER
i NO. I d
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 ! CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT. STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CONST
Date Applicant ARCHITECT OR TEL. ` O1 CLASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. J
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be t� TEL
= MO VALIDATION
deemed revoked. CONTRACTOR /� NO. Z CO
LICENSED CONTRACTORS DECLARATION LIC.
ADDRESS �10. /Q
I hereby affirm that I am licensed under provisions of Chapter 9 LIC $ '-
(commencing with Section 7000) of Divan 3 of the Business CITY N G� CLASS
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
,�-�'' ^(�' FINAL
�� ,
License Number �� Lic..ClassS.c��� SWIMMING POOL 5 ..�-q n� qr� LJ DATE � '•-
SPA ,1
Contract6r/a�-+� Date FT. FINAL O
VP
SO. BY _._.. _
I am exempt under Sec. SIZE _._.,
3 ( _. itY
0
B.BP.C. for this reason ELECTRICAL -?'V
Date: ( -id
Sinature Steel &Conduit Bonding Il—vJ'9
9 Conduits, Conductors, Equipment fn
SINGLE FAMILY - z
HOME OWNER-BUILDER DECLARATION PLUMBING_ ,
I hereby affirm that I am exempt from the Contractor's License
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
other work and the structure is not intended or.offered
for sale (Section 7044 B&P Code).. Swimming Pool Heater
CONSTRUCTION LENDING AGENCY fau
1 hereby affirm that there is a construction lending agency for APPLICANTTEL. _
the performance of the work for which this permit is issued (PRINT NO/ .
(Sec. 3097, Civ. CJ
Lender's Name ADDRES 1�
Lender's Address G
P.C. Fee$ J 0 • 3 Per Fee �v 3 (G' ''''t
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 11I
representatives is County to enter upon the above- Total Fee Q J,
ntioneG_pro a or inspection purposes.
ignature of p icont or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE '