HomeMy Public PortalAbout4940 DOREEN AVE_Swimming Pool__ u
� WORKERS' COMPENSATION DECLARAttCNN ,
[,hereby affirm that I haver certificate of cod-Int to ce, .. 'APPLICATION. FOR -COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers' Compensation Insurance, P91r
or a certified copy thereof (Sec. 3000, Lob. C.) 7EA20B r
Cf-875(II/BI(
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. -
a FOR APPLICANT TO FILL IN auuDING
Certified copy is filed with the county building inspec- �BUILDING / �q r/ ADDRESS (J
tion department _ ADDRESS/ ��Q 0 . g;6-fir+ ' t�. ��I^ LOCALITY _-
Date Applicant CITV �/ /PL-� 0, ZI Pi I '/ y/_ NEAREST
at
CERTIFICATE OF EXEMPTION FROM WORKERS' - 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 ZONE MAP
hundred dollars ($100) or less.) OWNER �P' �•41'•- NO. �y--"" NO. tf.rL
0 /'
I certify that in the performance of the work for.which this,-, SPECIAL
SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS yoN,z�o e�'/V Y� CONDITIONS
so as to become subject to the Workers'Compensation Laws. - DISTRICT STATISTICAL CLASS TYPE
CIT .t�9/Zl- 6 C i7y zip y/ 7�G CONST
Date Applicant ARCHITECT OR TEL _ 4rz0y CLASS NF PROC SED�Y
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER, - NO. J 1 / J
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 be TEL. $ // AOO VALIDATION
deemed revoked. CONTRACTOR .NO. V
LICENSED CONTRACTORS DECLARATION - LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. $
(commencing with Section 7000) of Division 3 of the Business LIC' - Y
CITY CLASS
and Professions Code, and my license is in full force and effect. d
DESCRIPTION OF WORK y (�/� LSI ��� C
License Number Lic. Class swum"k
NG
S^ I D,= •J O/ DIA EL /,—/0 'Q> D -P 4 1 7.,`� A V
SPA SIX 7' - 3S �h - 7 # e e e e 21 0
/ Q FINAL \/-
Contractor Date \ SO. FT. S•P ytB IS�� / BY 2r 80.64
-I am exempt under Seca SIZE / e.• N
B.BP.C. for this reason ELECTRICAL _ - e e o 60 6,4 0 Z
Date:
Signature Steel 8 Conduit Bonding ,O R.0 2-8 3
SINGLE FAMILY Conduits, Conductors, Equipment 0 4 17.b A
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License D # is e e o 0 3
/ Law for the following reason (Section 7031.5, Business and
Professions Code): P-Trap. - Gas System 2 - 2 3.7 3 8
(Qt I, as owner of the property, will do the plumbing and Anti-Syphon
�I electrical work. I, or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL. 0802-8 3
other work and the structure is not intended or offered _
for sole (Section 7044 ERE Code). Swimming Pool Heater'
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for � TEL. L�/y�_
APPLICANT iF_/J SIiPF_w/JE' -
the performance of the work for which this permit is issued (PRINT) NO. `/y 7�'
(Sec. 3097, Civ. C.). - D -
'/94�of ooarc Lr
Lender's Name ADDRESS
,ow,
LT C �
Lender's Address (,`p /(/
P.C.Fee$ d VZ WI Permit Fee 4 d-
I certify that I have read this application and sta a that the /
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee C,U• J
mechanical and plumbing construction, and hereby authorize Investigation Fee
representatives of this County to enter upon the above- Total Fee _
mentio d pr erly f r inspection purposes.
Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE