HomeMy Public PortalAbout6153 IVAR AVE_Swimming Pool__ WORKERS'CC(MPENSATION DECLARATION
I �ere6,,, affirm"that I'have a certificate of consent to self
insure, or p.certificclte of Workers' Compensation Insurance, APIPUC AY ON FOR 0DAMMATEDH -S��M�►1 RG [POM p[ ROT
• a.- ��jY�t��he((e��ofl!,,Se 380 C.) 76A208
(1� CE-875(11/81)
nv COUNTY OF LOS_ ANGELES BUILDING AND SAFETY
ertified copy is hereby furnishecl.
BUILDIN
eFtified cop is filed with the county bui ing ec- FOR APPLICANT TO FILL IN, ADDRESS ADDRESS
IL
i' dep nt. BUILDING z ,
Th 1 ADDRESS -LOCALITY)
ate Applicant 1 IIJV "rrS �,
NEAREST
CERTIFICATE.OF EXEMPTION FROM WORKERS' CITY ZIP . CROSS ST.
COMPENSATION INSURANCE SIZEOF ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE i PARCEL
(This.section need not be completed if}he permit is•for one EL USE ZONE MAP �/5
hundred dollars ($100)or less.) OWNER1106" �37NA off
I certify that.-in the performance of the work.for which this SPECIAL
permit is issued, I shall not employ'any person in any manner ADDRES ( CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CIZIP CONST.
Date Applicant IARTECT OR TEL. �, CLASS NO. / CA
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. 4 ,y/
Exemption, you should become subject to, the Workers'. - VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions 'or this permit,s hall be E . $ VALIDATI
deemed revoked. CONTRACTO N
LICENSED CONTRACTORS DECLARATION C '
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS
$
(commencing with Section 7000) of Division 3 of the Business LIC.
CITY '
and Professions C e ar>d y IJnse is in full fort CLASS ndsff t: -
DESCRIPTION OF WORK FINAL t
License Number Lic. Class C -Q SWIMMING POOL DATE J' V
Contractor ` . SPA `. FINA11
L O
SQ. FT. �- BY 2 6 2 A V
I am exempt under Sec. SIZE d
B.&P.C. for this reason # * o 0 0 2 1
ELECTRICAL � _
Date: I o 0 79.21
Signature Steel & Conduit Bonding
Conduits, Conductors, Equipment 0 0 0
SINGLE FAMILY 7 9,21 s
C?
HOME OWNER-BUILDER DECLARATION PLUMBING 4F I :D1 2_8 5
I hereby affirm that I am exempt from the Contractor's License
Law'for the following reason (Section 7031.5, Busiriess and P-Trap
Professions Code): _ Gas System,
1, as owner of the property, will do the plumbing and Anti-Syphon
i
electrical work. I,or my employees with wages as their z 2 6 6 3 A
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered , # o o o o o 3
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY 1 .- 27676
I hereby affirm that there is a construction lending agency for LICA
the performance of the work for which this permAppTEL.
it is issued LICA )- NO. D o o27676'
c�
(Sec. 3097, Civ. C.). (PRIN
Lender's Name ADDRESS 0 & 1 2-85
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 relating to building, electrical, Issuance Fee
mechanical and plumbing construction, and hereby authorize Investigation Fee o
epresentatives of. this County to enter upon the above- Total Fee
m ne roperty for ' sp ction purposes.
1 Signature of Applicant o Ag Date SEE REVERSE FOR EXPLAPIATORY LAINGUAGE '