HomeMy Public PortalAbout5450 HILTON AVE_Swimming Pool__ (
WORKERS'COMPENSATION DECLARATION T '
hereby affirm that I havecertificate of consent la self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insures or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (SyC. 3800, Lab. C.)/' T6A20B / , ..
1 _L •_O l.oman CE676(9164)
Poli y No. p y COUNTY OF LOS ANGEiES ., �' . "'BUILDING AND SAFETY
Certified copy is hereby furnished.
OFOR APPLICANT TO FILL IN BUILDING ��--yy�� �
Certified copy is filed with the county building inspeo ADDRESS d_2") late
tion department. BUILDING _ '
ADDRESS Y.�d as �e NEAREST LOCALITY
Date .�/9 Applicant `._'� /'"/h`��
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY pI le . ZIP CROSS ST.
COMPENSATION INSURANCE TRACT #3111 LST OF LOT NO. / MHP BASSESSOOK B%(/✓OR
PAGE �� PARCEL
(This section need not be completed If the permit is for one TEL ry�y�L E ZONE MAP -
hundred dollars ($100) or less.) OWNER NO, NO:
I certify that in the performance of the work for which this t SPECIAL
permit is issued, I shall not employ any person in any.manner ADDRESS H (/(� ` / CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY /r /G ZIP 1/750 1 CONST.
Date Applicant ARCHITECT OR TEL /'T I F CLASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER H NO. s% U • �/
Exemption, you should become subject to the Workers' L /� OAS, VALUATION
Compensation provisions of the Labor Code, you.must forth- ADDRES //
TEL h O� VALIDATION
with comply with such provisions or this permit shall be NO./f rV -2 S /oOD
deemed revoked. CONTRACTOR np OD
LICENSED CONTRACTORS DECLARATION ,sr� // `' /J LIC.
ADDRESS t1l p/K /[ NO. 62097
I hereby affirm that I am licensed under provisions of Chapter 9 LIC $
(commencing with Section 7000) of Division 3 of the Business CITY' 003'°/Hµ CLA55 S_3
;and Professions Code, add n �mly license is in full force and effect. DESCRIPTION OF WORK FINAL
License Number 4n9.r2 Q� / tic. Class C J ; , ►
DATE .
/hQAiNi Ll4v70 PC//GSSPA 44FINAL R
{ Contractor a, � ,^Date SO. FT. n/� V
am exempt udder Sec. ' SIZE t, BY / O
B.BP.C. for this reason ELECTRICAL 0
Signal / .L! /Gy/ ry Steel 8 Conduit Bonding - _ N
Conduits, Conductors, Equipment Z
SIN61fE FAMIV
n
HOME OWNER-BUILDER DECLARATION PLUMBING It1 �I1" ► "'
I hereby affirm that exempt from the Contractor's License
s
Low for the followingg r reason (Section 7031.5, Business and p Trop
Professions Code): Gas System ?jTk(
ElI, as owner of the property, will do the plumbing and Aati-Syphon `
electrical work. I,or my employees with wages as their
sole compensation,or o licensed contractor will do all MECHANICAL �. s
other work and the structure is not intended or offered
for sale (Section 7044 B8P Code). Swimming Pool Heater ,
=+07 _•,`�`;
_
CONSTRUCTION LENDING AGENCY .-, T--.,_
l tr _,
I hereby affirm that there is a construction lending agency for APPLICANT TEL, p• ,
the performance of the work for which this permit is issued (PRINT) �au7n Qr p NO. 11_1}(:jf 4°_- y_ .z T_+;
(Sec. 3097. Civ. C.). A
Lender's Nome / CHECK.s
ADDRESS S D oa/ RrK -
t_PIAN-j
Lender's Address ,G-/� / �D. �P
P.C. Fee b aJ r Permit Fee CO O
I certify that I have read this application and stole that the �}'' // {�
above information is correct. I agree to comply with all County Issuance Fee pe°7` /-y s.+ tIl_I�1�1-ri_It�l G�1`%,fi.0
ordinances and State laws relating to building, electrical,
mechanical and plumbing construction, and hereby authorize Investigation Fee / -n-
(O
representatives of this County to enter upon the above- Total Fee j
menti ed party for in tion_purposes. '
Signoture o ppOca o,Agent Dale SEE REVERSE FOR EXPLANATORY LANGUAGE