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HomeMy Public PortalAbout4930 BALDWIN AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION • I hereby affirm that 1 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 ", . CE876(3/84) Pa)icy No. Company COUNTY OF LOS ANGELES BUILDING AND_SAFETY Certified copy is hereby furnished. BUILDING Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS tion department. BUILDING ADDRESS 0 tis lk �Yti!lVQ,•. LOCALITY ell Date Applicant �' NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CITY e m L ZIP CROSS ST. COMPENSATION INSURANCE SIZE O ASSESSOR b TRACT LOT LOT NO. MAP BOOK TOO PAGE OO O PARCEL WD (This section need not be completed if the permit is for one TEL. t' 7lf USE ZONE MAP 1',9141 hundred-dollars ($100)or less.) OWNER ,, NO. 7 y y' /VS NO. I certify that in the performance of the work for which thisSPECIAL permit is issued, I shall not employ any person in any manner ADDRESS Q Il'l Ove- I 'CONDITIONS so as to become subject to the Wor ers'Co nsatio Laws. �+ { DISTRICT STATiSTICAI'CLASS TYPE PROCESSED BY r h CITY / eiVIVII /� ! ZIP � r� CONST. Date / '�1� V Applican ARCHITECT OR TEL: CPS, CLASS NO: NOTICE TO APPLICANT: If, afte aking this C fic e of ENGINEER NO. O Exemption, you should become subject to t e Workers' VALUATInON ti+ Compensation provisions of the Labor Code, you must forth- ADDRESS :: L,a.'••. p �: VALIDATION with comply with such provisions or this permit shall be TEL.CONTRACTOR NO. $ deemed-revoked. LICENSED CONTRACTORS DECLARATION LTC. ADDRESS ILNO. I hereby affirm that I am licensed under provisions of Chapter 9LIC. $ (commencing with Section 7000) of Division 3 of the Business CITY 10' CLASS and Professions Code, and my license is in full force and effect. DESCRIPTION OF WORK FINAL (� License Number Lic. Class SWIMMING POOL O/�4 © DATE © Contractor Date SPA FINAL //oma / U SQ. FT. 31` BY NSW'/rN�L+�/ at I cm exempt under Sec. SIZE B.&P.C. for this reason ELECTRICAL - Date: W Signature Steel & Conduit Bonding N g Conduits, Conductors, Equipment Z SINGLE FAMILY 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 _•' 's Professions Code): P Trap z-e Gas System �I, as owner of the property, will do the plumbing and Anti-Syphon a uu electrical work. I, or my employees with wages as their sole compensation,or a licensed contractor will do all MECHANICAL " s• other work and the structure is not intended or offered "" I for sale (Section 7044-B&P Code). Swimming Pool Heater CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for APPLICANT n TEL. r the performance of,the work for which this permit is issued (PRINT) �pe Cam a NO. y7 /-�7oS °'-' = - -' �' (Sec. 3097, Civ. C.). r ® L.H E`,tiil-4.Yu. Lender's Name ADDRESS' 3a a w!� Qi Lender's Address f' P.C. Fee$ r r p� Permit Fee I certify that I have read this application and state that the above information is correct. I agree to comply with all Count tl ordinances and State laws relating to building, electrical, Issuance Fee - mechanical and plumbing construction, and hereby authorize Investigation Fee representatives of is County to enter upon the above- Total Fee menu ed'proper or insp coon purposes. 12- 90 5i ature of Applicant Age Date SEE REVERSE FOR EXPLANATORY LANGUAGE