HomeMy Public PortalAbout6010 HART AVE_Swimming Pool__ Wc?RKERS"ClJMPENSA"TION DECLARATION
I hereby affirm,that I have a certificate'of consent tol self np y� �p 2 � ��tn �p/�y� �p ❑�❑� /� �p n nn
insure„ror a ceitificate of Workers' Compensafion Insurolpce, API UCA lI UOK IfN C®EVIII��IN/W"Il OR SUV�I1C/IIIIC/ll RG POM
Pr.a certified co the of (Sec. X800, Lab..C. c CE876 COUNTY OF LOSANGELES BUILDING. AND SAFETY
��bbjie copy ( gyp- ) ��j/ \t, .,
T ql V 5 \ •-1�l�W CE876(3/84)
Policy Na. om an
Certified copy'is hereby furnished.
FOR.APPLICANT TO FILL IN BUILDING
�. Certifi copy is filed with the aunty building ins ADDRESS
do .de o�rrttmenP. BUILDING
1 ADDRESS 1 , LOCALITY
Date Applicant L' ++, NEAREST *�1�
C1t7TTrJ- hA =� C ZIP` 1� CROSS ST. 5`#�,�.1•, �..t
.CERTIFICATE OF EXEMPTION FROM WO K SSIZE OF ASSESSOR
COMPENSATION INSURANCE• TRACT LOT OT NO.34k 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+�( �,G NO. rM NO.
1-certify that in'the performance,of the work for which this SAt1�'� SPECIAL
permit is issued, I shall not,employ any person in any manner ADDRESS i�V CONDITIONS
so as-to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSIED BY
CITY ` ZIP �`/ CON
Date Applicant ARCHITECT'OR TEL. fJx CLASS NO. :rj
NOTICE TO'APPL-ICANT: If, after• making this Certificate of ENGINEER NO. �rJC
Exemption, you. should become subject to the Workers' VALUATION
Compensation provisions of the Labor.Code, you must forth- ADDRESS
TEL. VALIDATION
/J /^//,�
with comply with such provisions or this permit shall be CONTRACTOR t NO. $ ! ® �
deemed revoked.
LICENSED,CONTRACTORS DECLARATION t LIC'
v NO. .
I hereby affirm that,l am licensed unADDRESS der provisions of Chapter 9 LIC. J� $
(commencirg with Section 7000) of Division 3 of the Business CITY ( ` CLASS
and Professions CVejnd��4icense is in full for affect. DESCRIPTION OF WORK.. FINALicense NumberCic. Clas ' SWIMMING POOL ; /�y, •7 L/ DAY
L C
/� /q� /cJ(/ vC ( '
:/ SPA 1,:: .. 1
a
El
Contractor Date �',
SO. FT. i
❑ BY 'lam
I am exempt'under.Sec. SIZE'',
B.&P.C. for this reason' ELECTRICAL
Date: Ab 6 9.6'A w
Steel &Conduit Bondingo.9 0!6,o n'
Signature' Conduits, Conductors, E ui ment' tc `� to
SINGLE FAMILY q P ("-'2 3',9..2 6 z_ .
HOME OWNER-BUILDER DECLARATION PLUMBING i °i° 2 3 9.2 6,5
I hereby affirm that I am exempt from the Contractor's License _ o.31 9-�`8-7
Law for the fallowing reason (Section 7031.5, Business and D ' 4
Professions Code): P.-Trap
Gas System
I, as owner of the property, wil,l,do the plumbing and Anti-.Syphon
electrical work. I, 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
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.3 -
(Sec: 3097, Civ. C.). 5
v��• D
Jender's Name ADDRESS
Lender's Address
P.C. Fee$ 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
ordinances-and State' laws rel ting to building, electrical, Issuance Fee
o 50
mechanical and plumbing con r ction, and he by authorize Investigation Fee
r s ntatives thi Coun enter upo the above- Total fee
nV nIi ned prop rt for i pe do urposes/tt _ -
1JC
a
Si nature of Appli ant r Agent / Date a SEE REVERSE FOR EXPLANATORY LANGUAGE
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