HomeMy Public PortalAbout6022 BURTON AVE_Swimming Pool__ WORKERS'CCQPEh1$AiON DECLARATI N
In liveley A}tim that I have a certificate of Iona as to' If I�P'L�I®rs. ®� S�HVRARN�4�G ®�� ������
insure, or a certificate of Workers' Compensatitn InsLr�'uce, wl COMBINATION
or a certified copy thereof (Sec. 3800, ob. C ) ]bA208
CE-875(1 I/81)y
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
_nQe,tified copy is filed with the c oty buildY.a insper ADDRESS (/ Q
tion de artme BUILDING
DZ9
ADDRESS Q (l O LOCALITY
pplicant
ate
NEAREST
RTIFICATE OF EXEMPTI FROM WORKERS" CITY E ZIP CROSS ST.
SIZE OF ASSESSOR
COMPENSATION INSURANCE
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed If the permit is For one / TEL p rp ZONE MAP
hundred dollars($100)or less.) OWNER f� LL-pp NO.a(J p NO.
I certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS - 4l (/lE- CONDITIONS
so as to become subject to the Workers'Compensation Laws. q DISTRICT STATISTICAL CLASS TYPE PROCES D BY
_ CITY - ZIP /�— CONST.
Date Applicant ARCHITECT OR TEL CLASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER ,� NO. 6-:?Z--75-2,3
y `VA POPL
Exemption, you should become subject to the Workers• AM VALUATION
Compensation provisions of the Labor Code, you-must forth- ADDRESS/,? y7�lOp 6
with comply with such provisions or this permit shall be f K VALIDATION
deemed revoked. CONTRACTO // C NO. 6 y
LICENSED CONTRACTORS DECLARATION
ADDRESS N/ E G � LICO. 9/� a�
I hereby affirm that I am licensed under provisions of'Chapter 9 . $
(commencing with Section 7000) of Division 3 of the Business LIC' `'� >_-
and Professions Code, and my license is in full force and effect. CRY CLASS =7�
_ .DESCRIPTION OF WORK -_7 8 24 A O
��r �• 1 L.S.h FINAL i v
License Number /�� LV Lic. Class J SWIMMING POOL >�' 4 q DATE '
�LZS �� 1 FIN D `. 00 ao2J OL
Contractor Date 50P FT. I ° ° 5 6 4 1J
c
am ez pt under Sec. •- SIZE B / W
❑ ^ ° 5640 w
B.BP.C. for this reason Dore: ELECTRICAL Z
1227- r?3
y�F
Steel 8 Conduit Bonding �I
Signature Conduits, Conductors, Equipment u
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING
1 hereby affirm that I am exempt from the Contractor's License D
Law for the following reason (Section 7031.5, Business and P-Tra
Professions Code): Gas System c�7 8 2 5 A
El 1, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. 1,or my employees with wages as their .
sole compensation,or a licensed contractor will do all MECHANICAL s I c 2 00.50
other work and the structure is not intended or offered >
for sale (Section 7044 B8P Code). Swimming Pool Heater t s ° ° 2 0 1,5 0
CONSTRUCTION LENDING AGENCY - r• I V r�• t
I hereby affirm that there is a construction lending agency for 12 2 7-�'3
APP
the performance of the work for which this permit is issued PRINT) NO. 6
) TEL'
(Sec. 3097, Civ. C.). ( D '
i
Lender's Name ADDRESS
Lender's Address 6 - V �' •! •. - �-
. -
I certify that I have read this application and state that the P.C. Fee S Permit Fee 1170
� t
above information is correct. I agree to comply with all County / 0 \ �• 1 �'
Issuance Fee ` t I `•
ordinances and State laws relating to building, electrical, '� t � �+11 •,
mechanical and plumbing construction, and hereby authorize Investigmion Fee 16
representatives l of this Count enter upon the above- Total Fee + 1
ioned grgp try for - c ur ses. R
Signmure of Applii5arYlor Agent Dat t' SEE REVERSE FOR EXPLANATORY LANGUAGE