HomeMy Public PortalAbout6362 GOLDEN WEST AVE_Swimming Pool__ WORKERS'COMPENSATIOI�ECLARATION
hereby affirm that I haver certificatepez tion In, Lanelf
, 'APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
Insure, or a certificate of Workers' Com nsatlon Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) 76A201B
CE-W5(11/81)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certlfled copy Is hereby furnished.
a Certified copy is filed with the county building Inspec- FOR APPLICANT TO FILL IN ADDRESS
tion department. BUILDING
AIX7kES5kwz LOCALITY
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CTTY i� ZIP �S ST.
COMPENSATION INSURANCE SIZE ASSESSOR
TRACT LOT LOT NO. Y MAP BOOK PAGE PARCH
is socsection need not b�completed ff the p�rmft Is oTEL. USE ZONE MAP
(ThJ
undred dollars (=100)or loss.) Owm3z ry NO. NO.
I certify that In the performance of the work for which this SPECIAL
permit Is Issued, I shall not employ any person In y manner ADDRESS CONDITIONS
so as to ome sublQct to the Work rs pen tion DI.Ml STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CLASS NJD
�- Dat Applicant ARaIf1FCTOR Ta-
NOTICE
TO AP 60
I ILL
If, offer making this Certificate of �'
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you-must forth- ADDRESS VAUDATION
with comply with such provisions or this permit shall be NCO _
deemed revoked.
LICENSED CONTRACTORS DECLARATION r..Z No (J
I hereby affirm that I am Ilcerued under provisions of Chapter 9 NO ;
(commencing with Section 7000) of Division 3 of the Buslness
CITY CLAu
and Professions Code, and my license Is In full force and effect. }
Q � DESCRIPTION OF WORK _ v
Llcpnse Number Ic. Class SWWIMING POOL Q�7 DATEV
�1 Q— r l�� SPA T ?— FINAL 0
Contractor IU ' ��Tr1 Date
❑ SD. FT. 6Y
I am exempt under Sec. SIZE ��// N
B.BP.C. for this reason ELECTRICAL C..O� z
Steel &Conduit Date:
ng
Signature Conduits, Conductors,Equipment r
SINGLE FAMILY 9 0 A 3A
HOME OWNER-BUILDER DECLARATION PLUMBING . ' 0 0 o 0 2 1
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and P-Trap [ 00 51,112
Professions Code): Gas System
I, as owner of the property, will do the plumbing and AntlSyphon 0 ^ 0 5 1,3 2 E
electrical work. I, or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL 0 2 1 7 — 8 Q
other work and the structure Is not Intended or offered 9 4 A
for sole (Sectlon 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY # 0 0 0 0 0 3
1 hereby affirm that there Is a construction lending agency for 4
the performancq of the work for which this perm4 Is Issued �NT ep� R NO U2- , .4 0 0 0
(Sec. 3097, Cly. C_).
Lender's NomeADDRESS :0r
Lender's Addresa
P.C_ Fss$ Perm It Fsa '
I certify that I have read this application and state that the
above Informatlon Is correct. I agree to comply with all County' ��FN
ordlnances and State laws relating to building, electrical,
mechanical and lalurribing construct) n, and hereby authorize Invnttgat,on Fee
represent ves Is C enter upo the bov Total Fe*
mentlo tion purposes.
Signature of Appl,cant or Agent Dab SEE REVERSE FOR EXPLANATORY LANGUAGE
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