HomeMy Public PortalAbout6328 ENCINITA AVE_Swimming Pool__ .WORKERS' COMPENOATION DECLARATION ,I
' I he eaffirm that havecertificate of consent to self APPLICATION FOR COMBINATION SWIMARING POOL PERMIT ful
insure,, or o certificate of Workers*
P9
kers' Compensation Insurance, 1r .
or a•certified copy thereof (S c 3800, Lab. C.) "76A20B
// 1 CES76(3/64)
PoIicy 4C QW,`-3� pony C - COUNTY OF LOS ANGELES BUILDING AND SAFETY.
Certified copy is hereby furnished. I_(.�- _
BUILDING
El Certified copy is filed with fbe building iospec- FOR APPLICANT TO FILL IN ADDRESS (;to3a7? IJ 4JG/LL)1 Cc,
tion d part J
nt. BUILDING �J..:. /
IPJAW�6 ADDRESS ��• LOCALITY-
Date Applicant NEAREST
CITY ZIP CROSS ST.
CERTIFICATE OF EXEMPTION FROM ORK RS' ' SUE O g ASSESSOR
COMPENSATION INSURAN TRA��/f ALq T Cp LOT NOCJ MAP BOOK PAGE I PARCEL
'(This section need not be completed if the permit is for one TEL. USE Z F MAP -
hundred dollars ($100)or less.) OWNER RA1L_0-44n 2 NO. NO.
I certify that in the performance of the work for which this t� I SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS d � �U�� CONDITIONS
-so as to become subject to the Workers'Compensation Lows. .7�iy ZtP DISTRICT STATISTICAL CLASS .TYPE CON PROCESSED BV
CITY /�l� S 3Io�
Date Applicant ARCHITECT OR TEL. C ( CLASS NO.
NOTICE' TO APPLICANT: If, after making this Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' ADDRESS a< /� //`� v •5 VALUATION
Compensation.provisions of the Labor Code, you-must forth- '
with comply with such provisions or this permil.sholl be TEL 0,('i $ 1 3 VALIDATI _
deemed revoked. CONTRACTOR .NO. .C)c
LICENSED CONTRACTORS DECLARATION1/�4._ ILII
LIC
ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 I.C. $
(commencing with Section 7000) of Division 3 of the Business CITY J t AJ ` CLASS CS ,
and Professions Code,and my h nse Is in full force and effect. DESCRIPTION OF WORK
�[ d m qC TI��/ FINAI �s
License Number / /v/ '-Lic. Class U 13 I �I '/L' / D �.1 ,Q 1•3 A ,
SWIMMING POOL GATE t
Contracto Date y`7 d7 SPA "L1J FINA�p^71/� # e e e e
❑ SO. FT L. f'/L U
' I am exempt under Sec SIZE SSz� BY I .,.- 8479
O
B.&P.C. for this reason ELECTRICAL CA co ag q7 q x
U
Date: W
nature Steel 8 Conduit Bonding .I Q27-88
Si
9 Conduits, Conductors, Equipment Z
SINGLE FAMILY - -
HOME OWNER-BUILDER DECLARATION PLUMBING '
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason ( P-ire ,Section 7031.5, Business and ' A''.01.4
Professions Code): D Gas System e o L Y J U
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I, or my employees with wages as their .102T-88
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 Hooter
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TE
the performance of the work for which this permit is issued (PRINT) N I D
(Sec. 3097, Civ. C.) /� /� /'
Lender's Name�� /�ADDRESS (DI C-0 !J A?'�- ;4&, ..( c,, �
Lender's Address �/t 9
P.C. Fee S 1 / 1 Permit Fee
I certify that I have read this application and store that the //' �
above information is correct. I agree to comply with oil County - ` V
ordinances and Slate lows relating to building, electrical, Issuance Fee
me<hani lumbIng construclion, and hereby authorize Investigation Fee
represe relives o his County to enter upon the above- Total Fee
mentio propert inspection purposes.
/ �7
Signature o1 Appl om or em Dote SEE REVERSE FOR EXPLANATORY LANGUAGE