HomeMy Public PortalAbout5922 BURTON AVE_Swimming Pool__ WORYc€RS'COMPENSATION DECLARATION -L 1
re (iii that I havecertificate of consent to self - APPLICATION FOR COMBINATION SWIMMING-POOL PERMIT- lu'
insusure,, or'a cerfifi:ate of Workers' Compensation Insurance, "-
or'a certified copy thereof (Sec. 3800, Lab. C,) 76A208 -
22' �IC� r� CE876(3/84)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. BUIUDtNG
Certified copy is filed with the county buildFOR APPLICANT TO FILL IN. ADDRESS
building inspec- ADDRESS
tion d partme nt. '- \t f BUILDINGLOALITY
Date II V Applicanl�/�rl�Lr, l \%µ16C ADDRESS ✓✓ ••ff�� NEEAREST
CERTIFICATE OF'EXEMPTION FROM WORKERS' 410
CITY .ZIP (J CROSS ST.
SIZE O ASSESSOR C2� PAGE I-/ PARCEL
COMPENSATION INSURANCE ' TRACT
SIZE
LOT NO. MAP BOOK J✓
(This section need not be completed if the permit is for one TEL. USE ZONE I MAP
hundred dollars(5100)or less.) OWNER R4 Atle, NO. I NO..
I certify that in the performance of the work for which thisr'q.77 � •1...._ -/ SPECIAL„ ',
permit is issued, I shall not employ any person in any manner ADDRESS T� (/ '�1 _ (CONDITIONS „s.t:,;,,,
so as to become subject to the Workers'Compensation Laws. ,I DISTRICT - STATISTICAL'CLASS TYPE PROCESSED BY
CITY µtil ZIP I { ,V - 'CONST.
Date Applicant ARCHITECT OR �! TEL ��jj CLASS NO.
NOTICE TO APPLICANT: If, after making this Cert ificote of ENGINEER 1I� Ih Z NO.�j,Z' ' �D� o/
Exemption, you should become subject to the Workers' - -" - VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS �s !. " ", VALIDATION
with comply with such provisions or this permit shall be f11I� NO�l7r-_ S
deemed revoked. CONTRACTOR T \' (� C�
LICENSED CONTRACTORS DECLARATION ADDRESS& • (yLi, u•�IzS -LIC
I hereby affirm that I am licensed under provisions of Chapter 9 5 - -
(commencing with Section 7000) of Division 3 of the Business LIC
CITY 'abVu,
and Professions Code, and my license is in full force and effect. DESCRI ION OF WORK '
�L , DATE
License Number �19j� czl 1� Lic. Class� SWIMMING POOL DATE LFA Z Z 43
Convactor�\�- ?(4T-� Date t) SPA }}��' - FINAL
FT - x
OSO. . JV BY -
I am exempt under Sec. SIZE V
B.&P.C. for this reason - ELECTRICAL
Dote:
Steel B t Bonding Signature Conduits, Conductors, Equipment O-
L,� - Z
.SINGLE FAMILY _
HOME OWNER-BUILDER DECLARATION PLUMBING . NiX: ,r
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and D 1 i OU 420 9
Professions Code): - P-Trop -
Gas System
1, 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 offeredli�
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY, _ _ c ' - )'tr`ID
I I�ereby affirm that there is a construction lending agency fory /L
APPLICAN 1� 1 C II �1L - TEL
(PRI
the performance of the work for which this permit is issued ) 6s I lire NO. C/O7 D ' ry r-nv r
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS I} "�,• - W,�� -_ . . CHANGE
Lender's Addressevr ,�� /1�/ J / '
P.C. Fee$ Permit Fee ri .J so
1 certify that have read this application toMion and state that the I Ii1 ll(-I l�ij i _t f 1'y 1 2
above information is correct. I agree to comply with all County - - n ^/`
ordinances and State laws relating to building, electrical, Issuance Fee O` -/.7 1 ,9_54 1 AN 7_4
mechanical and plumbing construction, and hereby authorize Investigatloo Fee �`
representatives of this County to enter upon the above- Total Fee
mentioned property for i s section purposes.
L(� �II h?Z.
Slgnam.e of Appllca or Agent D.te7 SEE REVERSE FOR EXPLANATORY LANGUAGE