HomeMy Public PortalAbout5339 GOLDEN WEST AVE_Swimming Pool__ i EPS'COMPENSATION DECLARATION
I"her.' that I haver certificate of consent to Self APPLICATION .FOR COMBINATION SWIMMING POOL" PERMIT
insure, certificate of Workers' Compensation Insurance, '
or a certified copy thereof'(Sec 3800, Lab C ) •76A20B
CE876(3/84)
Policy No Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished
Certified co FOR APPLICANT-TO FILL IN BUILDING ' i
py"is filed with the county building ins ADDRESS
tion•department BUILDING
ADDRESS 5339 GO 1 de n W e s t LOCALITY
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY Temple C l t ZIP 91780 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 Alice BarrOWReid N028r?-277 NO
I certify that in'the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person in any.manner ADDRESS same as above CONDITIONS
so as to become subject to the Workers'Compen a ws - DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CO ST
Date-�A-+S�Applicani y�✓(.(iCx� r ARCHITECT 0R TEL r � CLASS NO ,
•NOTICE TO APPLICANT •If, after making, tKis Certificate of ENGINEER NO
Exemption, you ,should become' subject to the- Workers' - - VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS
9�0 O VALIDATI
with comply with such provisions or this,permit shall be CONTRACTOR � �NO �TEL $ 21 1v�
deemed revoked
LICENSED CONTRACTORS DECLARATION LIC
ADDRESS NO
I hereby affirm that I am licensed under provisions of Chapter 9 LIC $
(commencing with Section 7000) of Division 3 of the Business CITY CLASS
and Professions Code, an 'my license is in full force and effect DESCRIPTION OF WORK
� FINAL
License Number Lic Class SWIMMING POOL DATE d
t �1 _
_Contractor Date SPA � FINSQ FT aBYI am exempt under Sec SIZE 8 t X 1 n 0
1 O
B&P C'for this reason ELECTRICAL �•�
Date I jB W
Steel &Conduit Bonding 0
Signature Conduits, Conductors, Equipment - z
SINGLE-FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License l s
Law for the following reason (Section 7031 5„Business and o
Professions Code) :- P.-Trap
Gas System Y .�
j, as owner of the property, will do the plumbing and Anti-Syphon r
electrical work I,or my employees with wages as their 4 7 Z 8'A
sole compensation,or a licensed contractor will do all MECHANICAL # o s,e'o 0 3 I
other work and the structure is not intended or offered Q.
for sale (Section 7044 B&P Code) ' Swimming Pool Heater Q ! -:1 0'&O O
CONSTRUCTION_LENDING AGENCY
I hereby affirm that there is a construction lending agency for !TEL ,� O 0•,0
the performance of the work for which'this permit is issued
APPLICANTPTNO
(Sec 3097, Civ C ) ( Q 6 0 5 8 6
r s
Lender's Name ADDRESS
Lender's Address /\J
I'certify that I have read this application and state that the P C Fee$ Permit Fee 7
above ihformation is correct I agree to comply with all County .> (�
ordinances and State jaws relating to building, electrical, Issuance Fee
mechanical and plumbing construction, and hereby authorize Investigation Fee
representatives of This.County to enter upon the above- Total Fee
mentioned property for i ctio u oses
Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE