HomeMy Public PortalAbout4906 HELEO AVE_Swimming Pool__ WORt_RS'COMPENSATION DECLARATION
I hereby affcer that I hover certificate'of consent to self Q D a o O nA, FOR n OR 0 PHAVp` H ��p'/���1pHP POOL PERMT
nsurc, or a certificate-'of Workers' Compensation Insurance, gPIPUCAVO 0 tl1N ® IICN
or a•cert fiieed�coopy.thereof (Sec. 3800, Lab. C. 76A20e
{L�ol �._f.�' CE876(3/84) . . - _
Policy No. Compnny .-'4 —T COUNTY OF LOS ANGELES ..,.'BUILDING AND SAFETY
Certified copy is,,hereby furnished. BUILDING�
1/ /
Certified copy.is filed:with the county building,i'nspec- FOR APPICANT TO FILL IN ADDRESS "��,` ,.• - '
tipn.clepaltmenl, BUILDING
ADDRESS to
Date Appl[cant " NEAREST
CERTIFICATE OF EXEMPTION'FROM WORKERS' CITY ri ZIP... CROSS 5T, .
SI OF ASSESSOR
COMPENSATION.INSU RANCEjG fJ. nn�9
TRACT LO LOT NO., MAP BOOK r/g. PAGE--v{..... PARCEL L�
(This section need not be completed if the permit is for one TEL. USE ZONE - MAP
hundred dollars ($100)or less.) OWNER' �. NO. NO.
o�
P certify that in the performance of•the work forwhich this- r `w SPECIAL•
permit is issued; I.shall not employ any person in any manner ADDRESS. U� / CONDITIONS t'
_- .
so as to become subject to the,Workers'Compensation Laws. DISTRICT STATISTICAL CLASS' TYPE PROCESSED BY
CITY ZIP CONST. t
Date *,Applicant ARCHITECT O TEL.' l° CLASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of
ENGINEER �C NO. �� `
Exemption, you should °become. subject to the. Workers' ADDRESS ?j� VALUATION
Compensation,provisions of the Labor Code, you must forth- VALIDATION
with comply with:such provisions or this permit, shall be { ;9�� e TEL.' $ "�� ''
deemed revoked; CONTRACTOR 11 �Vv > NO.,
LIC
LICENSED CONTRACTORS DECLARATION ���������QQ £1
I hereby affirm that I am.licensed under'provisionsrof Chapter 9 ADD SS IA{'�/�NO. I{f
(commencing with Section 7000),of Division 3 of the Business LIC.
CIT CLAS $
DES PTION O. ORK S
and Professions Code;and my license is in full force and effect., '
l/f� FINAL q'
' License Number ' � lic. Class `' _� WIMMING POOL: D,
S IJ DATE
Contractor Date SPA U FINAL'
❑ SQ. FT'
16m exempt under Sec. SIZE q 4.. BY
8.8P.C. for this reason ELECTRICAL
Date: ;
`Steel & Conduit Bonding 1 Vii ' ' z
CL
Lti
Signature . Conduits, Conductors; Equipment
k n,.
SINGLE FAMILY
HOMEOWNER-BUILDER'DECLARATION. PLUMBING
I'hereby affirm that I'am exempt from the Contractor's License, D
Law for the following reason (Section 7031.5, Business and P-Trap
a
-.Professions Code) P ° :
_Gas System _.
I, as owner of the property, will do the plumbing and Anti-Syphon µ r
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'
ale. Section 7044 B&P Code _
for s #;
( ) Swimming Pool-Heater
_I
YJ
CONSTRUCTION LENDING,AGENCY
I hereby affirm that there is a construction'lending.agency for APPLICAN p�rJ�, q1 /�q'� o=TEL.
p permit, (PRINT) Vf ` �1�`7!�" .NOS t.. ..
the erfornionce of the work for,which'this is issued -
(Sec. 3097, Civ. C.,)
Lender's Name ADDRESS ®!i
.... �.. _..r .,._
Lender's Address /p / w r -
P.C. Fee$ / j� Permit Fee Z(Fl O . 6 „
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County �7�
ordinances and State laws relating to building, electrical, Issuance Fee pt
mechanical and plumbing co struction, and hereby authorize investigation Fee s
representatives of thi's o ty'to enter upon the bove- Total Fee D
mentioned propert for i ection purposes. �J
Signature of A plica or Agent ate SEE REVERSE FOR EXPLANATORY LANGUAGE '