HomeMy Public PortalAbout5635 HALLOWELL AVE_Swimming Pool__ V$ORKERS' COMPENSATION DECLARATION
1-h�ex�c �tff m that I.'-tave a certificate'of consent to self
insure or a certificate!'df Workers' Compensation Insurance, APPUCAT OM POIR coGUImmknow SMAPA G 70M PERPM
or a certified,copy thereof (Sec,3800, L b. C 76A208
CE876(3/84)
Policy tCompan ✓l COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy,is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the my building.inspec- ADDRESS
ti n d par}ment. BUILDING
ADDRE S LOCALITY
Dat Applicant \ NEAREST
ERTIFICATCOF EXEMPTIO ROM WORKERS' CITY ZIP CROSS ST. 1H,
COMPENSATION I URANCE 1.SIZE OF ASSESSOR
TRACT LOT LOT.NO. MAP BOOK PAGE PARCEL
(This section need not be complete if the permit is for oneTEL. USE ONE MAP
hundred,dollars;($100)or less.) OWN R. N NO.
I certify that in the peFformance-of the work for which:4his l SPECIAL
permit is issued, I shall not employ any person in any manner ADDRE S CONDITIONS
so as to become-subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY CC>Iryt ZIP - �Y/ CLASS NO. CONST.
Date Applicant ARCHITEC R TEL
NOTICE TO APPLICANT: If, after making this Certificate of
ENGINEER n/` N
Exemption, you should become subject to -the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRES 0 C4 ., l)
O VALIDATION
with comply with such provisions or this permit shall be `$ O Vb '
with
revoked. CONTRACTOR N
LICENSED CONTRACTORS DECLARATION LIC.
ADDRES � Q
I hereby.affirm that I am licensed under provisions of Chapter 9 LIC. /1 $
(commencing with Section 7000).of Division.3 of the Business CITY rn CLAS
and Professions Code,and my license is in full fo e and effect. DESCRIPTION OF WORK
fir—/�� FINAL
License=r6)-2�O Lic. Cla s SWIMMING O LCJ DATE� oContraDate SPA FINA O
OSQ Fr. sY �6 9 7 8 A
I'am exempt'under Sec. SIZE tY
B.&P.C. forELECTRICAL this reason # o 0 0 0 21 F
Date: Uj
Steel & Conduit Bonding I °,°.6 U 5
Signature Conduits, Conductors, Equipment
SINGLE FAMILY a 0.0 6'&.0 5.5 z
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License Q SD 6=,8 7
Law for the following reason (Section 7031:'5, Business and P-Trap
Profess ions'Code): Gas System 6'9-7..9 A
EJ I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I, or my employees with wages as their #,o,0 0 0 ko 3
sole compensation,or a licensed contractor will do all -MECHANICAL ( .° 2 3 9.2 6
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater _
CONSTRUCTION LENDING,AGENCY ° 2 3 9.,2 6'v
I hereby affirm that there is a construction lending agency for APPLICANT TEL.
the performance of the work for which this permit is issued (PRINT,) -NO. D 0 5„0 6.7 8 7.
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS
Lender's Address
P.C. Fee-i 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 -71/
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical*and plumbing construction, and hereby authorize Investigation Fee i 1
representatives of this County to enter upon the above- Total Fee
men 'o+d Aropertection purpoyes.
Ig a e of Appl, ant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE