HomeMy Public PortalAbout6100 IVAR AVE_Swimming Pool__ WORKERS COMPENSATION DECLARATION ❑/� nn/�y�-p (gip (�p�p (�(�(�(� �;p n p �Fl �p
I he`e;y affi n +hat�4,f oW a ce'.6oXmtpe'of consent to self /�I7p P C l�TPON F"Oln`;"'I OUIN��I A i1 11H• J� V1Y UVt11/VI MMU [POOLL' ER 141-'
' insure, or a'cert�ficar;; of,Workers.Com ensation Insurance, 1n11T L4 l�(n1
or a certifi d copy thereof (Sec. 3800, Lab C:) 7sa2oB
,CE876(3/84)
Policy N o`mpan _COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished,
FOR APPLICANT TO.FILL IN BUILDING0
Certified copy is filed,With the cou ty buil 'nnspec- ADDRESS
tiol de ortment., r% t. BUILDING
ADDRESS _ nn LOCAL
Date Applica NEAREST
CITY ZIP CROSS.ST.
CE TIFICATE OF EXEMP FROM WORKERS' - SI E OF. ASSESSOR - -
COMPENSATIO SURANCE;' TRACT LOT LOT NO. MAP BOOK PAGE 'PARCEL.
(This section need not be comple ed if the permit is for one
TEL USE ZONE MAP
hundred dollars ($100)or less.) OWNER NO �j NO.
I certify that in the performance'of the work for which this tL SPECIAL
permit is issued, I"shall not employ any person in any manner ADDRES } CONDITIONS
so as to become subject to the Wor,k.er,'Compensation Laws, DISTRICT STATISTICAL CLASS TYPE PROCESS BY
CITY ZIP_ CONST.
Date Applicant ARCHITEC R TE' '7 CLASS
�NO._
NOTICE TO APPLICANTIf, after, making, this Certificate of
ENGINEER N
Exemption, you should become subject to ,the. Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRES % t
VALIDATION.
with comply with such proy,isions.or this permit shall be
deemed revoked. CONT CTO �0, YtSAN '
LICENSED'CONTRACTORS DECLARATION LIC: f!
ADDR SS �� NO. O
I hereby affirm that-I am licensed under provisions of Chapter 9 $
(commencing with Section 7000) of Division 3 of the Business LIC:
and Professions Code,and my license is in full force and effect. CIT SCCLASS
ERIPTION OF WORK
_ FINAL
License NumITZI; Lio. Cl ss SWIMMING POOL DATE �' P
z 69'2..5 A
Contr or Da SPA F AC.
SQ. FT: Y U
ram exempt under Sec. SIZE � � � eot o 7 9.2 1 (�
B.&P.0 for this reason 7 9>211 v
ELECTRICAL T 4,;2 7'+` 8 7 .
Date:'
•
W
Steel&rConduit'Bonding #X14 9,941
Signatur Conduits, Conductors;,,Equipment 4 -27
76 Z
SINGLE FAMILY PLUMBING _
H M OWNER-BUILDER DECLARATION -.6'27 6,.7.6
o x 8
I hereby affirm t I am exempt from the Contractor's License „
L
aw for the toll ng reason (Section 7031.5, Business and D
42 7
'Professions Code): P-Trap.
Gas System
I,"as owner of the property, will"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 saleSection 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.
97
(Sec. 300, Civ. C.).
Lender's Name> ADDRESS D"
Lender's Address 6 IJ
P.C.Fee$ Permit Fee
I certify that I have read this application and state that the !
above information incorrect. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee
'mechanical and plumbing construction, and hereby authorize Investigation Fee
rep, sentatives of this Co}}}!!!���ty to, enter. upon the above- Total Fee
men, ned pr per for inctii7 purpos s.
S1gn Lure of A-Mlrcont or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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