HomeMy Public PortalAbout9517-19 GARIBALDI AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
hereaffirm that I have certificate of content to .elf APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
Insurecertificateor a certificate of Workers'
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kers' CdrhpensaTlon Insurance,
or a certified co t ereof , Lab. C:) W-0018 Daw 311111�enxle
Policy No pany t®°I COUNTY OFAOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby fumished.
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Certified copy is filed with the coun building Inspec- FOR APPLICANT TO FILL INgp '
tion department. BIJ DW,
_ ADDS LOCALITY
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Data App cat NEAS7
CERTIFICATE OF EXEMPTION FROM WORKERS' CrrY ZIP CROSS ST.
COMPENSATION INSURANCE 51g OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK4KE—!> PAGE RARCEL
is secHon need not be completed If the perm}t Is'for one TEL USE ZONE kS&CWVPC1
undred dollars (=100)or less.) OWNER NO .I certify that In the performance of the work for which this I y�� CIAL
permit Is Issued, I shah not employ any person In any manner ADDRESS NDMCN5soas to become subject to the Workers Compensation Laws. DISTRICT TISTC41 CLASS TYPECfrY ZIP LASS NO. r CONST.
Date Applicant ARCH RECT OR TEL
NOTICE TO APPUCANT: If, after making this Certificate of -ENGINEER NO. ✓
Exemption, you- should become subject to the Workers' ADDRESS V4VATION
Compensation provisions of the Labor Code, you must forth- IO
VAIJDATN
with comply with such provisions or this permit shall be CONTRACTOR NCO $ 6 �D�
deemed revoked. �
LICENSED CONTRACTORS DECLARATION ADDRESS US NO ,` O/
I hereby affirm that I am Ilcerised under provisions of Chapter 9 C $
(commencing with Section 7000)of Division 3 of the Business �y r CLASS ) d
and Professrons and my II Is in full force nd DESCRI OF W04ZK FKA1 O
License N ber D LI, Class SWIMMING POOL D DATO �� U
�� _-� CL
Contractor e SAA p17 BR1A1
SD. F7. - � / / BY U
I am exempt under Sec. 51g
W
B.BP.C. for this reasonIL
EIFCTRlCA1 <n
Date: Z
'Steel &Conduit Bonding
Slgrxrture Conduits, Conductors, Equipment
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that f am exempt from the Contractors License , 23
Law for the following reason (Section 7031.5, Business and P-TrapAA��
Professions Code): Gas System V#L•t•T.a
❑ 1, as owner of the property, will do the plumbing and Antl-Syphon 3D37 . 4 16.06
electrical work 1, or my employees with wages as thelr
sole compensation, or a Ilcensed contractor will do all MECHANICAL
other work and the structure Is not Intended or offered for
sale (Section 70.4" B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there Is a construction lending agency for F ''
the performance of the work for which this permit is Issued DC TEL
ANT 3 TEM
(Sec. 3097, Civ. C.). , TOTAL ���•1�
Lender's Name ADDRESS
`�
Lender's Address Permit Fee V *>5O 11h 7a
P.G Fee; IG• (� r 1 '
I certify that I have read this-application and state that the
above Information Is correct. I agree to comply with all County7
crdlnancds and State laws relating to bulldinQ electrical, N&"aryCe Fee
cqll mechanical arKd plumbing construction,and her, authorize Inwsnpatbn Fee / / �y/ i ji }-f� 1 ` %+;
ro ntatives of this County to enter upon t e above- Total Fee
nt ned pr for l6spectlon purposes. 1 At' S•221
gnature of Applkant or Agent Date SFE REVHtSE FOR EXPLANATORY LANGUAGE