HomeMy Public PortalAbout4948 BALDWIN AVE_Swimming Pool__ W9RK±eS COMPENSATION DECLARATION r I SI{j
I hereby affirm that I have a certificate of consent to self }
insJre ora certificate of V�,orkers Compensatiog Insurance APPLICATION FOR COMBINATIO : AIMING POOL PERMIT
or arc h t co ' ere( (Sec 3800 Lab C ) 76 201B _ y
Po y�No company CE {(I 1/81) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy i3 hereby furnished
BUILDING { v
�of ed copy is filed with t county building mFOR APPLICANT TO FILL IN spec ADDRESS— 3/
n depa tme t BUILDING lio �% 4
ADDRESS U.S(YJ LOCALITY
Date Applican NEAREST
CITY
CERTIFICATE OF EXEMPTION FROM WORKERS �� ZIP CROSS ST r
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT A LOT NO MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one TEL qrUSE ZONE MAP
hundred dollars ($100) or less ) OWNER NO �t NO
I certify that to the performance of the work for which thiss —( SPECIAL
permit is issued I shall not employ any person in any manner ADDRESS 4 CONDITIONS
so as to become subject to the Workers Compensation Laws DISTRICT STATISTICAL CLASS TYPE PROLE ED BY
CITY ZIP CLASSNO
CONST
Date Applicant ARCHITECT OR TEL
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO
Exemption you should become subject to the WorkersADDRESS J VALUATION
Compensation provisions of the Labor Code you must forth o / VALIDATION
with comply with such provisions or this permit shall be TEL
CONTRACTORCO,kL 04 NO �s ZZ�/ $ t't—
deemed revoked
LICENSED CONTRACTORS DECLARATIONLIC
I hereby affirm that I am licensed under provisions of Chapter 9 LIC
ADDRESS ` �S NO 5
(commencing with Section 7000) of Division 3 of the Business L
and Professions C de and my license is in full force and effect CITY CLASS C��3 d
DESCRIPTION OF WORK FINAL O
License Numbe Lic Cla SWIMMING POOL 2 � DATE!/ �� 00 / O
ContracC9 Date SPA -/n 7 FINA o IFS
SQ FT By z20b6A W
I am exempt under Sec SIZE CL
,° 21 to
B&P C for this reason ELECTRICAL _ ��a� d 7 ' ' Z
Date a° ° 79211
+ dQ Steel & Conduit Bonding
Signature �'T� Conduits Conductors Equipment o o+0 7 9 2 1 '0
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION'--'�, PLUMBING I ; 0618-84
1 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 z 2 0 6 7 A
sole compensation or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered # 00 0 0 0 3
for sale (Section 7044 B&P Code) Swimming Pool Heater 2 °12f 5 6 1 3
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANTTEL ° 0 256 1 3 6
the performance of the work for which this permit is issued (PRINT) G NO,
(Sec 3097 Civ C ) ,
Ott 1 8-84
Lender s Name ADDRESS [
Lenders Address P C Fee$ i / Permit Fee .'2j 4 5 �R—� ✓
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 jaws relating to building electrical Issuance Fee /0 — ,To
mechanical d plumbing construction and hereby authorize Investigation Fee ^^ / l
represent tiv of this County to enter u o the above Total Fee P�Y . / 3 1
mention/d operty for inspection purpose
t
re of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE