HomeMy Public PortalAbout5754 CLOVERLY AVE_Swimming Pool__ WONKERS'COMPENSATION DECLARATION
hereby affirm that I havecertificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a c rti ied copy there f (Sec. 3800, Lab. C.) 76A20B
�__� _F12 Q/ J•ff• CE876(3/84)
Policy No. ompany 1��/1r F ��y I COUNTY OF LOS ANGELES BUILDING AND,SAFETY
1_1Certified copy is hereby furnished.
APPLICANT TO FILL IN BUILDING
�ertified copy is filed with the county building inspec- FOR ADDRESS
tion department. BUILDING
ADDRESS A4 2 LOCALITY
Date '. Applicant
• NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITYrj� ZIP CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is For one TEL. USE NE MAP
hundred dollars($100)or less.) OWNER NO 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 , CONDITIONS
so as to become subject to the Workers'Compensation Laws. fffSTRICT STATISTICAL CLASS'' TYP PROCESSED Y
CITY ZIP L� y/ CST.
Date Applicant ARCHITECT OR TEL. CLASS NO.'
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
Exemption, you should 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 beTEL.«� / 5 S1/yFl j VALIDATION
deemed revoked. CONTRACTOR (9 NO.L /
LICENSED CONTRACTORS DECLARATIONLIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS � NO.j )1oz $
(commencing with Section 7000) of Division 3 of the Business LIC. Q 2.1,2 A
CITY
and Professions Code, and my license is in full force and effect. S o 0 0 e
'7 DESCRIPTION OF WORK FINAL 0 Q 1 '
License Number 1961 7— Lic. Class6!_ SWIMMING POOL_ pr` DATE , Z
ContractodfALI�.P(/Le1s�2 Date*_7710 SPA li`V�✓\ \` o 1.5�J U r
FINA 7 1 8'.;-
O
SO. FT. FI Q 1. I V��V 0
I am exempt under Sec. SIZE _71 Q
B.&P.C. for this reasonU
ELECTRICAL
a
Date: 0
Steel &Conduit Bonding !3
SINGLE FAMILY
Signature Conduits, Conductors, Equipment # 9 y' �, CL
LtJ
tZ
HOME OWNER-BUILDER DECLARATION PLUMBING I o 3 511,7 6 (f)
I hereby affirm that I am exempt from the Contractor's License ® Z
Law for the following reason (Section 7031.5, Business and P-Trap 0 0 3 5'1.7 6 5:
Professions Code): Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon o7. .1 8�-8 8
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 offered
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
the performance of the work for which this permit is issued PRINT EL. _
(Sec. 3097, Civ. C.). ( I
Lender's Name ADDRESS
Lender's Address
P.C. Fee$ Permit Fee A,26
1 certify that I hove read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee I
mechanical and plumbing construction, and hereby authorize Investigation Fee
representatives of this County to enter upon the above- Total Fee r�V
mentioned propy r inspection purposes.nou 'DA MA A
.0
t ,
azure o A Ilcont or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE