HomeMy Public PortalAbout5927 AVON AVE_Swimming Pool_12/29/1988_swimming pool ORKERS'COM'SENSATION DECLARATION "
,reby affirm that I (.D-,c a certificate of consent to self
inure, or a certificate of Workers' Compensation Insurance, APPLICATION, FOR COARNMATION SWIMPANG POOL PERAW u
r a certified copy thereof,(Sec. 3800, Lab. C. 76A20B -
�' /`e� CE876(3/84)
olicy N'o g C .ZLampany., / / '!J COUNTY OF LOS ANGELES BUILDING AND SAFETY
Jl Certified"copy is hereby furnished.
�( FOR APPLICANT TO FILL IN BUILDING
ad Certified,copy.is filed',with the y building inspec- ADDRESS
tion department. BUILDING ,/O ` e
_/ L ADDRESS Y /�/ LOCALITY 7
)at O Applican NEAREST
CITY ZIP CROSS ST.
.7777
CERTIFICATE OF EXEMPTION FROM WORKER '
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
This section need not be completed if the permit is for one TEL / USE ZONE MAP
wndred dollars ($100)or-loss.) OWNER N
NO.
certify that in the performance of the work for which this j 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 PROCE ED BY
CITY ZIP CONST.
Date-x,, Applicant ARCHITECT OR y-� y' l� TE CLASS NO.
NOTICE' TO APPLICANT:. If; after making this Certificate of ENGINEER `� / N
Exerrntion, you should become subject to the Workers' /� i/ f 'VALUATION
p
Comensation provisions of,the Labor Code,.you-must forth- ADDRESS 2t n.i
with comply with such provisions or this permit shall be / T L. .� ® VALIDATION
deemed revoked. CONTRACTOR N " /rI 00
LICENSED CONTRACTORS DECLARATION ! 1j LIC.
thereby affirm that I am licensed under provisions of Chapter 9 ADDRESS / �� NO. $
(commencing with Sectionf7000) of Division 3 of the Business CITY / fO CLASS
and Professions Co77de, and m• license is in full force and effect. DESCRIPTION OF WORK "'
License Numbers` % Lic. Class�� SWIMMING POOL /N_
FINAL
/ ��^ :. -DAT ✓/� �. . � �-=
Contractoc /Js•J Date SPA ��' n—�• .,,, 0'
/� f �j FIN
'I am exempt'-under"S'eC. SIZE FT 94v ��" ��
B.&P.C. for this reason ELECTRICAL p4.2 A
U
Date: c Lil
Steel &Conduit Bonding 3 O
Signature Conduits, Conductors, Equipment to
SINGLE FAMILY I .1 53'.00 z
HOME OWNER-BUILDER DECLARATION PLUMBING o e !''U(
I hereby affirm that I am exempt from the Contractor's License 5 a �Q,_
Law for the following reason-(Section 7031.5, Business and
'" P Trap ( 2 2 9�' 8
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 ccmpensation,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 c `
CONSTRUCTION LENDING AGENCY - -�-• + .,,
I hereby affirm that there is a construction lending agency for y 1`
APPLICANT /���--�jj/� TEL.
the performance of the work for which this permit is issued (PRIN'�, _� NO.�
(Sec. 3097, Civ. C.).
Lender's Name ADDRESSP)0'/
Lender's Addressi1 r
P.C. Fee$ Permit Fee - (1
I certify that I hove read this application and state that the
above infor on is correct. I agree to comply with all County
ordinances n State laws relating to building, elezo
ctrical, Issuance Fee o r✓
meth I a d plumbing construction, and hereby authorize Investigation Fee
repr en ativ s this County to enter upon The above- Total Fee
me io ed piijfy r inspection purposes.
Sign Lure o a or gen Date SEE REVERSE FOR EXPLANATORY LANGUAGE