HomeMy Public PortalAbout5734 KAUFFMAN AVE_Swimming Pool__ WGRKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent'to self
insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or a certified copy thereof Sec. 3800, Lab. C.) 76A20B
CE876(3/84)
Policy No f f om any � �� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING r
DI/Certified copy is filed with the county building inspec- ADDRESS M
tion department. BUILDINGADDRESS ,�7 LOCALITY
Date 6 Applicant e NEAREV CITY � � �i ZIP 1-7ec CROSSSST. � r
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF ASSESSOR
COMPENSATION INSURANCE TRACT LOT LOT NO. MAP BOOK PAGE I PARCEL
(This section need not be completed if the permit is for one TEL. _ �/ USE ZONE MAP
hundred dollars($100)or less.) OWNER NO6NO.
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 ADDRESS CONDITIONS
so as to become subject to the Workers'Compensation Laws. 15,0
TRICT STATISTICAL CLASS TYPE PROCES D BY
CITY ZIP CONS
Dote Applicant ARCHITECT OR TEL. CLASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
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 shall be TEL. $ t� VALIDATION
deemed revoked. CONTRACTOR NO Z VC/L,�'&V
LICENSED CONTRACTORS DECLARATION LIC.
ADDRESS NO.105'c
I hereby affirm that I am licensed under provisions of Chapter 9 LIC �r $
(commencing with Section 7000) of Division 3 of the Business CITY L CLASS
and Professions Code, and my license is in full force and effect. DESCRIPTION OF WORK
FINAL ,
License Number �y�•,w Lic. Class C� t J SWIMMING POOL � DATE
Contracto
LYiI� MT?f eD E:2 Date 6 SPA FINAL
SO. FT. BY
0 1 am exempt under Sec. SIZE ) hV/1Cr.
VV O
B.&P.C. for this reason ELECTRICAL
Date: W
Steel'& Conduit Bonding
Sinature �-
9 Conduits, Conductors, Equipment fn
SINGLE FAMILYz
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
Professions Code): P Trap
Gas System I WI ACCT.v
0 1, as owner of the property, will do the plumbing and Anti-Syphon -,-I-r
L r
electrical work. I, or my employees with wages as their •= •r .:,:�::.>=�_
sole compensation,or a licensed contractor will do all MECHANICAL T
other work and the structure is not intended or offered ��- �
for sale Section 7044 B&P Code). Q/
( ) �Swimming Pool Heater TOTAL 222 - 83
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 24
APPLICANT TEL._ t•' '� y•i�1t
the performance of the work for which this permit is issued (PRINT) NO , ;�Hi�ls� o(!Ij
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS lfj Ge I�w
c Aln _
Lender's Address1-1 �1- i-)(Ii '4trZ�� LI
P.C. Fee$ Permit Fee ,3-3— }.�^1G -
I certify that I have read this application and state that the033228 1 AM iye;
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee 3: 00
mechanical and plumbing construction, and hereby authorize Investigation Fee �� ` �J�
representatives this County to enter upon the above- Total Fee
men 'Toned pro er 'Tor inspection purposes.
S gnature of pplicant or Agent Da SEE REVERSE FOR EXPLANATORY LANGUAGE