HomeMy Public PortalAbout9862 LEMON AVE_Swimming Pool__ WORKFga' COMPENSATION DECLARATION
I hereby'`dittrm that I have,a certificate-of consent to self
insure, or a certificate of Workers' Compensation Insurance, APPLICATION, FOR COMBINATION S' 1WIMING. PO®L PERMIT
.or a certified copy thereof (Sec 3800, Lab C ) e 76X208 '
tCE676(3/84) - - ►!•,
Policy NornpanyS� T'��1 ti�L1, COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnishedBUILDINO/ ;
Certified copy,is filed with the countytbuilding inspec- FOR APPLICANT TO FILL IN ADDRESS
tion department BUILDING j�
ADDRESS �'� /�L"`U/J rT��'�L� " LOCALITY C' "
Date Applicant, NEAREST
CITY- Z)1,- • C. CROSS ST
CERTIFICATE OF'EXEMPTION°FROM.WORKERS' ZIP Q-
COMPENSATION'INSURANCE /��ti T SIZE OF ^ ASSESSOR ^�
TRACT jp,�p. LOT LOT NO " .� 'MAP BOOK 3• 3 PAGE Q�� PARCEL a�
(This section need not'be completed`if the permit'is for one TEL / USE ZONE MAP
hbndred dollars ($100) or less.) OWNER IC I- r.; 0f2A44 Agr.,N 'f SF7=��S
I'certify that in'the performance of the work for which this / SPECIAL
permit is issued, I shall not employ any person iri any manner ADDRESS 17,RA AM CONDITIONS
so as to be_come'subl'ect to the Workers'-Compensation Laws d �f DISTRICT STATISTICACCLASS TYPE ' PROCESSED BY
C
�/�/� t -•y CITY, '(+,J �� ZIP �IC�O ! ICLASS•N0 CONST „e
Date `� Applicant (' ARCHITECT O A - r }TEL " V
NOTICE TO APPLICANT If, after making this Certificate of ENGINEER AA G �)j�M,4fJN0 X3387 ' ���
'Exemption, you should become subleet to the 'Workers' �) '
ADDRESS Q � V&/J /� t_ -VALUATION � Ct •
Compensation provisions of the Labor Code, you must.forth- h VALIDATION
with comply with such provisions or this permit shall be CONTRACTOR Cf OL.L1� NO p $
!� �UQ
TEL
deemed,revoked j/
LICENSED CONTRACTORS DECLARATION ADDRESS o2♦;p Lr, I�LLC NO
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 CS3
and Professions Code,and my license is in full force and effect DESCRIPTION OF WORK'
.� � 1 V . "4�4�-X_. FINAL
License Number Lic Class SWIMMING POOL DATE
SPA .
Contractor r d`Y'""r+"""' Date i FINAL
FT
e'l am exempt•under Sec SIZE SQ iti `;1L/Z' _ r D t, BY
B &P C -for this reason ELECTRICAL f— r
Date _ y - :? - A! - a << _ - W
Si nature Steel &Conduit Bonding -
9 Conduits, Conductors, Equipment
SINGLE FAMILY. ?
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that')am exempt from the Contractor's License
Law for the following reason (Section 7031`5,-Business and P-Trap " �•�• n
Professions Code) _Gas System
! :Y� '.{:Q
I, as owner of the property, will do the plumbing and Anti-Syphon � � '��'4� •=��tg,s_3!
electrical work 1, or my employees with wages as tHetr _ _ --i s ;',L _
sole compensation,or a licensed contractor will do all MECHANICAL r-
other work and the stfucture is not intended or offered , '7 -
for sale (Section 704488P Code) Swimming Pool Heater
CONSTRUCTION LENDING AGENCY
at 4 r<n •a a`'
I hereby offirm'that there is-o construction lending agency for APPLICANT TEL V ,°' , CHECK
a `Sa L`•„ t;r
the performance of the work for_whi•ch this permit is issued (PRINT)?,o0 TC L.L'/L1- N030,7�-511(jif -
(Sec 3097, Civ C , f
VA1-L� '/ ryi� t `- ltE
Lender's Name- ADDRESS L
Lender's'Address- 959
.yc '
P C Fee$ �/ .TVam Permit Fee Q 4:. v '•_Itis I^i E 1�I j �.r' i�`-,
I certify that I have read this application and state that•the _ ,...
above information s correct•1 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
representatives of this County to enter upon the above- Total Fee �E/llp O y
mentioned property or inspection purposes
c'� /
Signature of App i nt or Agent - ate SEE REVERSE FOR EXPLANATORY LANGUAGE