HomeMy Public PortalAbout6221 HART AVE_Swimming Pool__ WpftKERS' COMPENSATION DECLARATION.
•I that I hpve a certificate of consent to self np �5� �p ❑� �p
insure or'a,certificote of Workers' Compe+nsatipnTasurance, ' " "QPkCLS�C/n111� N FOR COP&)�p�JQVON MRONG pO®d PERANT
or a certified cnpy thereof (Sec. 3800, Lab C.j t,!' 76A208
� rj��y 10E876(3/84) - -
Po icy N Company COUNTY OF LOS ANGELES BUILDING'A ND SAFETY
Certified copy i's hereby furnished.
BUILDING
Certified,copy is filed with�the county building FOR APPLICANT TO FILL IN g inspec- "' ADDRESS ' f
tion department. BUILDING �J iMET
Date " ADDRESS �il LOCALITY
NEAREST
CERTIFICATE OF EXEMPTION: OM WORKERS CITY ZIP. t� CROSS ST.
COMPENSATION INSURANCE - SIZE OF ASSESSOR
TRACT LOT LOTNO., MAP.BOOK PAGE, PARCEL ,
(This section need not be completed if thepermit is for one , pp TEL. USE NE MAP
hundred dollars($100)or less.) NO.,
OWNER N NO:
I certify that in the';performance of the work for which this- SPECIAL
permit is issued, I-shallnot employ any person'in any manner ADDRESS kk CONDITIONS.
so as to become subject to the Workers'Compensation Laws: ; DISTRICT- -STATISTICAL CLASS. TYPE PROCESSED BY
CITY ZIP CONST.
Date Applicant ARCHITECT OR TEL: Af— CLASS NO.
NOTICE TO APPLICANT If, after making this Certificate_of`
ENGINEER NO. �/6^'i •
Com ensat onou should'. become-,subject,to the Workers" VALUATION a '
Exemption y ADDRESS
p provisions of.the•'La6or Code, .you ymust forth- ,qd ,, VALIDATION .
with comply with such provisions.or this.,permit shall.be l 't�v-�L" �T $ 0,'r
deemed revoked. CONTRACTOR l r(/[0
r - _.��. .
- IC. . . _
LICENSED CONTRACTORS DECLARATION ADDRESS f� ii 1
I hereby affirm,ahat_I am-licensed under provisions of Chapter 9 w "$' 2052,3A
LIC
(commencing with Section 7000) of,,Division.3.of:the Business CITY CLASS
and Professions Code,and my license is in full force and.effect. .• # c ° ° ° 2
DESCRIPTION OF WORK FINAI 1
License Number ' Lic. Class SWIMMING POOL DATE ) ° ° 9,6"8 2•
Contractor` i r `v Date SPA
FINAL o oc `C�
6.8 2.2 V
O SQ FT.,.•
SIZE
�o BY i-
I am exempt,under Sec: � a 2 514 8 8. O'
B.&P.C. for this reason ELECTRICAL
Date:
Steel & Conduit,Bonding
Signature Conduits, Conductors;Equipment t
N
SINGLE FAMILY Z
HOME OWNER-BUILDER DECLARATION PLUMBING a z 0 5 2 4 A _
• I hereby affirm that-I am exempt from the Contractor's License , # 0 0 0 0 0 3
Law for the-following reason,(Section 7031.5, Business and, P_Trap0.
Professions Code'):.' :,Gas-System„ a (.: 3r1 4,2 6
I, as owner of the property, will do the plumbing and Anti-Syphon x
electrical work. I, or my employees with wages as their 3 i1 4.2 6-c3
sole compensation,or a licensed'contractor will do all MECHANICAL8 2 5;
'Other
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT_ TEL
the performance of the work for which chis permit is issued
(Sec. 3097, IpRINT) �DJ� D
Civ'. C.).
Lender's Name ADDRESS
Lender's Address IPermit
P C Fee$- Fee
U _ '. '
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„relating to building, electrical, Issuance Fee l t -
mechanical and plumbing construction,and hereby authorize Investigation Fee
representatives' of this County to enter upon the above- Total Fee i o- „
mentionedqty for inspection purposes.
4,A
gnoture of A plicont or Agent Date - ' . .'SEE REVERSE FOR EXPLANATORY LANGUAGE - '