HomeMy Public PortalAbout5632 GOLDEN WEST AVE_Swimming Pool__ RS'COI ENSATION DECLARATION
I her y affirm that I have a certificate of consent to self
insure, or d certificate ofJjWorkers' Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or q certified copy_ther Sec 3800, Lab ) 76A20B
n -� CE876(3/84)
PoI,�I�Q Jo" C,uJmpany COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is heby furnished
�r �j FOR APPLICANT TO FILL IN BUILDING ' /►_
}syr Certi ted copy is filhd with t e c building mspec- ADDRESS` 1C:O
't`— tion epart enty BUILDING
vY ADDRESS LOCALITY
Date C O(,Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM W KE CITY ZIP CROSS ST
COMPENSATION INSURANCE SIZE F ASSESSOR
_ TRACT LOT LOT NO MAP BOOK PAGE PARCEL
(This section need notbe completed
eted if the permit'is for one , /'7 JELL USE NE MAP
hundred dollars $100)or,loss. OWNER v Cr
O NO
1 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 !�' CONDITIONS
so as to become subject to the Workers'Compensation Laws / DISTRICT /STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP -Y r �p NST
CHITECT R TEL CLAS NO
Date Appl;cant ARNOTICE TO APPLICANT If, after making thii Certificate of ENGINEER NO J• t
Exemption, you should become subject to the Workers' �7 N VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS ( J f ( ' 't VALIDA
with comply with such provisions or this permit shall be TEL
LL $ ��'• 7
deemed revoked CONTRACTOR qdJ
LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO
LIC $
(commencing with Section 7000) of Division 3 of the Business
and Professions Cod d�I`�e is to full force and effect CITY - Il�/�a CLASS'
// DESCRIPTION OFF WORK FINAL
License Number Lic Class S SWIMMING POOL DATE
j�� ( SPA - t
FINA.� ../�'
Contractor,�� ab/J Date SS FT FI 1�`_ 1
I am exempt under Sec SIZE I'o 0
9j Q
❑ B &P C for this reason ` ELECTRICAL - L-A_ 4f.J 2!,; 0 i.2 1 "8 8 U
77Date O
Steel &Conduit Bonding ;
Signature Conduits, Conductors, Equipment �' W
SINGLE FAMILY + CL
HOME OWNER-BUILDER DECLARATION PLUMBING ° W
1
I hereby affirm that I am exempt from the Contractor-s License y e Z
Law for the following reason (Section 7031 5, Business and P-Trap'
Professions Code) Gas System
1, as owner of the property, will do the plumbing and Anti-Syphon U14 1 c=7
electrical work 1,or my employees with wages as their
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 Heater
CONSTRUCTION LENDING AGENCY / �' -^•tib 7 )�;
I hereby affirm that there is a construction lending agency for APPLICAN TEL /) ^ f
the performance of the work f which this permit is issued (PRINT •, NO ` (1E4 i _'
® `
(Sec 3097, Civ ) 1 a /
L'ender's Name ADDRES (4 Iv �L/
Lender's Address �l J
P C Fee E PermitFee vvv c
I certify that I have read this application and state that the /
above information is correct I agree to comply with all County
ordinances and State jaws relating to building, electrical, Issuance Fee
mecha and plumbing construction, and hereby authorize Investigation Fee
repres Hiatt of this County to enter upon the a ove- Total Fee �� - ?i y �'•;a _ y
menti per for inspection purposes
Signa ure of
Appl'CaLr..41gent Date SEE REVERSE FOR EXPLANATORY LANGUAGE