HomeMy Public PortalAbout5703 ENCINITA AVE_Swimming Pool__ WC^^RKEPgS'rOMPENSATION DECLARATION
1 fie�eby aftMm,lhatAI hi o certificate of consent to self
insure; ora certificate of Workers Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or a certified copy thereof (Sec. 3800, Lab. C) ;6A20B
CES76(3/84)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished - -
❑ BUILDING 7D3 E/1 /��
Certified copy is filed with the county building inspec- AlPPLICANT TO FILL N ADDRESS J� 77)
lion department. UILDIN .S�d3�NG�N�jf1 LOCAIITV //� !�•�
Date - Applicant' /��6L T /J p• NEARCROSEST.
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY �Erq G / . ZIP %/ 7 OD
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT SIZE
LOT LOT.NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the Permit is for one �/t1 / TEL 77��77p USE ZONE MAP
hundred dollars ($100)or less.) OWNER6i� �/� NOp�DS I7 NO.
I'certify that in the performance of the work for which this n� �— / SPECIAL - --
permit is issued, I shall not employ any person in any manner ADDRESS `J 703 /rGIN� CONDITIONS'
so as to become subject to the Workers'Co penso.on Laws. pp DISTRICT STATISTICAL CLASS TYPE - P/ROC BY
_ �/r/� CITY 6/r1 SLE C�7 ZIP i7OoCONST.
Date Applicant
•' �-' ARCHITECT OR TEL - C1.455 N0.,
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. tll
Exemption, you should become subject to the Workers ADDRESS VALUATION
Compensation provisions of the Labor Code, you must forth- , VALIDATION -
with comply with such provisions or this permit shall beNO- S
deemed revoked. CONTRACTOR
LICENSED CONTRACTORS DECLARATION - LIC'
ADDRESS NO /�
I hereby affirm that am licensed under provisions of Chapter 9 LIC $ 7 d-00
-0 0
(commencing with Section 7000) of Division 3 of the Business CITY CLASS -
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK1.
y
FINAL '
License Number Lic. Class SWIMMING POOL �sX DATE I` �� ,^ � C11 u� U
El K(/// 0.✓ Y/ly! r
,Contractor Date SPA FINAL ..' 0
SO.EFT. 3�S BY. ti )- yI GQJW
I am exempt under Sea / r� C)
B.BP.C. for this reason ELECTRICAL !/!Yn a Yi�II U
Date: Gh/, Le�!l/LLL ;y W
an
Steel 8 Conduit Bonding 666""" �/ ( e • 6 2 4 8 Tn
Signature Conduits, Conductors, Equipment 'n � Z
SINGLE FAMILY - - - - + ON ra/�'i • ee'6248� —
HOME OWNER-BUILDER DECLARATION PLUMBING /
I hereby affirm that I am exempt from the Contractor's License (/(� ,0 a 1 4 4-8 6
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
YY��II electrical work. I, or my employees with wages as their ;!l!5 2 S 2 A
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered - # o e e e e 3
for sole (Section 7044 B&P Code), Swimming Pool Heater
CONSTRUCTION LENDING.AGENCY 5 s
I hereby affirm that there is a construction lending agency for APPLICANT TEL. o
the performance of the work for which this permit is issued (PRINT) - - NO. - 8 1 4 z
(Sec. 3097, Civ. C.). . D
Lender's Name ADDRESS
.lender's Address -
P.C. Fee S I Permit Fee
certify for have read this application and state that the / /O SA t ,• ,
above information and is correct. agree to comply with all County v�' Issuance Fee
ordinances and State laws relating to building, electrical, `
mechanical and plumbs n, and hereby authorize In.estigation Fee I S.
S D
representative is County to a ter upon the above- Total Fee _
mention prop qr pection put ses.
v
7!S•-g,6
Signotare o Applicant or Agent I SEE REVERSE FOR EXPLANATORY LANGUAGE