HomeMy Public PortalAbout5120 FARAGO AVE_Swimming Pool__ r - ,
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P
3VORKeRS' COMPENSATION DECLARATION x
hereby affirm that I havecertificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers'
p
kers' Com ensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C. 76A20B
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Policy No.?M% 1-4
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. BUILDING
Certified copy is filed with the county b ilding"nsp C- FOR APPLICANT TO FILL IN AD _
DRESS � /
tion department.�• ' BUILDING J t y
�LJ ADDRESS : / +1-0-f i-4 C ? LOCALITY IL r
Date ( Applicant Z � r� tJ / NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY C it r C ( IP `r / y CROSS ST. y
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 y� ,1 UL. , U NE MAP
hundred dollars ($100)or less.) OWNER /_A.-J 6 �{� C NO.
I certify that in the performance of the work for which thisl n / SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS /�� � /T Go CONDITIONS
so as to become subject to the Workers'Compensation Laws. �L�t / t _ DISTRICT- STATISTICAL CLASS TYPE PROCESSE BY
CITY f-1 �- L �J( ZIP t �) CONST
Date Applicant ENGINEER NO.OR. _7_ v� NO CLASS NO.
NOTICE TO APPLICANT: if, after making this Certificate of /
Exemption, you should become subject to the Workers' ADDRESS 3 , j � CIAlf, Aj �; VALUATION
Compensation provisions of the Labor Code, you must forth- ( � VALIDATION
with comply with such provisions or this permit shall be /� _ TEL`. /y{ .� j1'J $ /> '> 0 v
deemed revoked. CONTRACTO6"G AJ T(./12 .z 0 _ 1. V
LICENSED CONTRACTORS DECLARATION ADDRESS �—�l L LI 31X 0
I hereby affirm that I am licensed under provisions of Chapter 9 �•� NO ' o $
'1 LIC ( 53•/ _
(commencing with Section 7000) of Division 3 of the Business p G CLASS /
CITY � �J �-� °�'1 G r`t.�
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
3,i C' N?41— C a7 � I 0 /L' � 6 ❑ FINAL Z _� ► >"
License umber i Liptc. Class s� _ SWIMMING POOL DATE .�
Coniractorl�G!r VIZ DaJr\e C/ C�. e J SPA ,t// ❑ F1 ~r 2 9 7.0 A V
SQ. FT.
I am exempt under Sec. SIZE ��� # o o o o 2 1
0
B.&P.C. for this reason ELECTRICAL '' I o ? 73.64
]364 w
Date: �.
Steel 8 Conduit Bonding 1 /� 73,64'.
Signature Conduits, Conductors, Equipment j(amr�--� r/
SINGLE FAMILY Z
HOME OWNER-BUILDER DECLARATION PLUMBING 09, 20-85
I hereby affirm that I am exempt from the Contractor's License
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
El electrical work. I, or my employees with wages as.their 720297. 1 A
sole compensation or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered # b o 0 o o3
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY +c 0 2 5 8.O O
I herebyaffirm that there is a construction lending agency for
tg g y APPLICANT TEL. � _
the performance of the work for which this permit is issued. (pR� T�.� �L- NO. ��� 0 0 2 5 a 0 05
(Sec. 3097, Civ. C.). [� _ F ,
Lender's Name ADDRESS /lh�)�/ /� L C`�LST t1►�' 9 2 0—8 5
Lender's Address
P.C. Fee$ 3 b Permit Fee
I certify that I have read this application and state that the _
above information is correct. I agree to comply with all County /� c /)
ordinances and State laws relating to building, electrical, Issuance Fee v J v
mechanical and plumbing construction, and hereby authorize Investigatlon•Fee , p d
represeotativ�es f this .Coun"ty to enter upon the above- Total Fee 0
26
men)ioned rty fo�Fi spe ion purposes.
;' J _ �
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j nature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE