HomeMy Public PortalAbout5120 KAUFFMAN AVE_Swimming Pool__ WORKERS'COM'ENSATIOt41 DECLARATION.,
I herebyaffirmOthat) have to certificate'of-consent,to sel`
insure, or'a_certificate of Workers' Compensation Insura ce,
6A20B ,.. r ..
P�✓,thereof ( ) / .. CE876(3/84)
or,a-certified coy Sec; 380 Lobb. C. ,
Policy No: Company / COUNTY OF LOS ANGELES. BUILDING AND SAFETY
Cerf.&ed copy is hereby furnis ed'
FOR APPLICANT TO FILL IN BUILDING
7pt Certified copy is filed with the ounty b ilding i c ADD;.,ESS
tion department. G BUILDING }}f�7
AD RESS _i5/2G✓ rl LOCALITY
Datevzz&Applicant' NEAREST '
C RTIFICATE Of,EXEMP FROM WORKERS' CITY P.. CROSS ST. �
COMPENSATION INSURANCE SIZE OF ASSESSOR .
TRACT LOT LOT NO. MAP 800K AGE PARCEL
(This section need not be completed if the permit is for one - TEL US ONE MAP
hundred dollars ($100)or less.) OWNER /,. �7 / Z't'o
NES"�f/� NO.
1 certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person'in any manner ADDRESS d. l/jc`' /(�. CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE- OCE SED BY
CITY ` ZIP �� CONST.
Date Applicant ARCHITECT O Q TIL. CLASS TIO.
NOTICE TO APPLICANT:pf; after making this Certificate of ENGINEER
Exemption, you should.become subject to the Workers'
ADDRESS VALUATION p ;
Compensation provisions of the Labor Code. you must forth-- C Cis
with comply with such provisions or this permit shall be: TEL. / $° �� ALIDATION
deemed revoked. CONTRACTOR NO. f? DD6► X /
LICENSED CONTRACTORS DECLARATION LIC. '
ADDRESS/ 0Q (� dr'�J .�`�
I hereby affirm that I am licensed under provisions of Chapter 9 $
LIC.
(commencing with Section 7000) of Division 3 of the �
,Business CITY CLASS e-7- l
and Professions Code,and my license is in full force and effect. , T - u '
DESCRIPTION OF WORK FINAL �}
/ �
License Number lic. Class SWIMMING POOL ' DAT 1
- / gW�ZX739,9 nom.
r //
Contractor Date SQ. FT F`t. /�`AA y`t 1 // o so 0 0
aI am pt under'Sec. SIZE .2.1 O
B.&P.C. forlhis reason ELECTRICAL ®'
7 9.2 v
'
Date:
Steel &Conduit Bonding Q 2 8
Signature: Conduits, Conductors, Equipment t ( N
SINGLE FAMILY :jFt i ' z 7 4.0.0 A Z'
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that]am exempt from the Contractor's License : # o o.o oto 3
Law for the followingreason (Section 7031.5; Business and P-Trap - 27676
Professions Code): Gas,System 1
I, as owner of the property, will-do the plumbing and Anti-Syphon o -'2767 610
electrical work. I,or my employees with wages as'their
sole compensation,or a Licensed contractor will do all MECHANICAL Q 7,Q 2:8 7
other.work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPUCAry TEL.
the performance of the work for which'this_permit is issued (PRINK NO,
(Sec. 3097, Civ:C.).
Lender's Name ADDRESSr
L- 01 _ ` ..e
Lender's Addressr7 Z�
P,C..Fee$ 2-1 Permit Fee rJ— ,6.I certify that I have read this application and state that the
above information is correct. I agree to comply with all County J�
ordinances and State laws relating to building, electrical, lseuance Fee U
mechanical and plumbing construction, and hereby authorize Investigation Fee
representatives of this unty to enter upon the above- Total Fee
m e on urposes.
ignature of App icant or Agent j D to SEE REVERSE FOR EXPLANATORY LANGUAGE-
4 i