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HomeMy Public PortalAbout4946 KAUFFMAN AVE_Swimming Pool__ WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, APPd CABOIN COQ c(DIRA o DMAYMN SWURONG POGO d PER07 or a certified copy thereof (Sec. 3800, Lab. C.) 76A20B CE-875(11/81) L Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING . Certified copy is filed with the county building inspec- ADDRESS �r tion department. BUILDING ADDRESS LOCALITY Date Applicant G NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CITY ZIP CSO. CROSS ST. � COMPENSATION INSURANCE SIZE OF 2 ASSESSOR TRACT s LOT C) LOT NO. ':J. MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one i TEL. Z� USE ZONE MAP hundred dollars ($100)or less.) OWNER — O© L NO. /� NO. (� I certify that in the performance of the work for which this _ _ �f`� / SPECIAL permit-is issued; I shall not employ any person in any manner A ADDRESS �• ( CONDITIONS so as to become subject to the Workers'Compensation Laws. _ DISTRICT STATISTICAL CLASS TYPE PROCESSED BY Q , TY' LN C ZIP O !O CO ST. Date�a Applicant - 04 RCHITECT OR TEL: CLASS NO. / NOTICE TO APPLICANT: If, after making is Certificate of E NEER NO. !/ Exemption, you should become subject to the Workers' ADDRESS VALUATION Qqp Compensation provisions of the Labor Code, you must forth- �— with comply with such provisions or this permit shall beTEL. $ ��Q VALIDATION deemed revoked. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with,Section 7000) of Division 3 of the Business LIC. and Professions Code,and my license is in full force and effect. CITY CLASS CL #, DESCRIPTION OF WORK El FINAL D V - License Number Lic. Class SWIMMING POOL � / Q/n/ - DATE gOFT. FINAL 0 SPA' ontractor Date ,/fd ❑ . (G7 T BY `.S P —�J LU am exempt under Sec.• SIZE lll.JJ/ IL H B.&P.C. for this reason ELECTRICAL Date: Signature Steel &Conduit Bonding Conduits, Conductors, Equipment SINGLE FAMILY HOME OWNER-BUILDER DECLARATION PLUMBING I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and P-Trap 1 5,2 1 A Professions Code): Gas System 0I, as owner of the property, will do the plumbing and, Anti-Syphon # 0 0 0 010 7j electrical work. 1, or my employees with wages as their' 2 0 -'8'9.2-6 sole compensation,or a licensed contractor will do all MECHANICAL o 0'0 8 9,2 b other work and the structure is not intended or offered(Section 044 B&P Code). Swimming Pool Heater t for sale S 7 0 5. 2 5'-8 4 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for APPLICANTf TEL, the performance of the work for which this permit is issued (PRINT). o �4 NO. (Sec. 3097, Civ. C.). D Lender's Name ADDRESS Lender'sAddress P.C.Fee.$ Permit fee !f119 - 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 buildin 9``electrical, Issuance Fee mechanical and plumbing construction, avid hereby authorize Investigation Fee represent 'ves of this County to enter upon the/above- Total Fee menti ne ropers or insp on purposes. I! LIZ Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE