HomeMy Public PortalAbout5933 AVON AVE_Swimming Pool_6/27/1994_pool WORKERS'COMPENSATION DECLARATIGN
I hereby affirm that I have a certificateof consent to self
insure, or a.certificate of Workers' Compensation Insurance, APPUCAUGH FOR c(DA 0 9MAY&ON SY7pAMMG, P001 MAN 3
or a certified copy thereof (Sec. 3800, Lab. C.) 76A208 -
CE876(3/84)
Policy No. Company COUNTY OF LOS ANGELES ,j -BUILDING AND SAFETY
7. Certified copy is hereby furnished.
BUILDING
El .
Certified copy is filed with the county building inspec- FOR APPLICANT T FILL IN 'ADDRESS
tion deparf?nent. BUILDING
ADDRESS LOCALITY
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY / �C/ IP CROSS ST. G��(-I 4s
COMPENSATION INSURANCE SIZE OF ASSESSORTRACT LOT �' LOT NO. MAP_BOOK �J PAGE�/,n;L IRA'RCELZ �,
(This section need not be completed if the permit Is for one TEL. USE ZONE MAP
hundred dollars($100)or less.) OWNER NO. NO.
I certify.that in the performance o e work f 'r which this SPECIAL fry
permit is issued, I shall not emplo a erson' any manner ADDRESS CONDITIONS ��i/�`
so as to become subj ct to t r rs'Com nsalion Laws. DISTRICT STATISTICAL CLASS TYPE` PROCESSED BY
CITY ZIP x ' CONST.
Date Appl' ant ECT OR TEL. `pt
LASS NO":Q/
NOTICE TO APPLIC NT. f, afte making this Certificate of ENGINEER NO. �'[[1l� ✓'/ i%'�% —¢:
Exemption, you ould 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 L �,�/; $ VALIDATION
deemed revoked. CONTRACTOR O.
LICENSED CONTRACTORS DECLARATIONIC
ADDRESS S NO.,j �
y
I hereby affirm that I am licensed under provisions of Chapter 9 $ i
(commencing with Section 7000) of Division 3 of the Business LIC.
and Professions Code, nd ' Ii nse is in full force and e ct. CITY CLASS G
DESCRIPTION OF WORK ❑ FINA'L' ,
License Number Li Class�r SWIMMING POOL � n t
DATE
2&_q
Contract o aSPA' El FINAL
SO. FT. d
�PD, am exempynder ec. SIZE BY Q
.&P.C. for tn ELECTRICAL
_ - �
Steel &Conduit BondingE111 ? �+j .J�7 w U
Signature Conduits,.Conductors, Equipment c �� / t Ld
A ICY 0-
HOME OWNER-BUILDER DECLARATION PLUMBING Z
I hereby affirm that I'am exempt from the Contractor's License D ?
Law for-the following reason (Section 7031.5, Business and '.~ `-
P-Trap
Professions Code): Gas System i'S_ t =v
I, as owner of the property, will do the plumbing and Anti-Syphon --.3
electrical work. I,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL t
other work and the structure is not intended or offered
for sole (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for n ''i I —=`t'
APPLICANT
the performance of the work for whichTEL.
( NO.this permit is issued PRINT I-;E�"(`.�;
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS Ht_
t_fi
Lender's Address / /� Q c7 �h �l j/ )LJ;1..
P.C. Fee$ 00, Permit Fee o^� t-• f""
4certify hLbingconstruction,
is application and statethat the anI agree to comply with all County �� a and relating to building, electrical, Issuance Fee 6l andonstruction, and hereby authorize Investigation Fee �� � ' (_ ^yE lel!sunty to enter upon the above- Total Fee � .proection purpo
Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE