HomeMy Public PortalAbout6415 LIVIA AVE_Swimming Pool__ WOR4S'COMP!NSATION DECLARATION
insure,'or
a i,tm that I have r certificate of consent to self /�[�[i3�UCATION FOR COMBI All 0®llral e��F1 BE6'GPA1N,g, PQ% PER9� T
msure,'or a certificate of Workers' Compensation Insurance, C�11rI� l+ �,ls
or a certified copy thereof (Sec 3800, Lab C ) 76A20B, ,. - - . - '
(y/0„ �O CE076(3/B4)
Poli of�2g omp any COUNTY-OF,LOS ANGELES ,BUILDING AND SAFETY '
F-1- Certified copy is hereby furnished
BUILDING
�erhfied copy is filed with the county,buildmg mFOR APPLICANT TO FILL IN spec- ADDRESS -
zz
tion department BUILDING
ADDRESS - LOCALITY-
DateApplicant / NEAREST
r CITY Gr LON ZIP �! CROSS,ST Q �-
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE O ASSESSOR
COMPENSATION INSURANCE TRACT LOT LOT NO MAP BOOK a, _ PAGE PARCEL
(This section need not be completed if the permit-is for one TEL USE ZONE ESPECIAL
hundred dollars ($100)or less.) ^ • OWNER ' NO �J
I certify that in the performance of the work for which this }�permit+s issued, I shall not employ any person to cgny manner - ADDRESS ` r
so as to become'sublect to the Workers'Comp
-Laws DISTRICT STATISTICAL CLASS TYPEPROCESSED BY
CITY ZIPCONST
�--- A CLASS'NO
Date ApphcanT ARCHITECT OR TEL r(� 7 "
'NOTICE TO APPLICANT If, after making this Certificate of ENGINEER NO
Exemption, you should become sub(ect-to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth-: ADDRESS '
with comply with such provisions or this permit'shall be /` �jj���� TEL 5 VALIDATION,
deemed revoked, CONTRACTOR /F /' "SCJ NO ``
LICENSED,CONTRACTORS DECLARATION ADDRESS NCG ((yQ;-�-
'I hereby affirm that I am hcensed•under provisions of Chapter 9 5 0 9 b"4 A
(commencing with Section 7000)'of Division 3 of the,Business / LIC
CITY (r CLASS��3
and Professions Code,and my license is m full fo"rce ad effect # o o'o,0 2
/ , DESCRIPTION OF W RK FINAL (:0 - 9(136
License Number/V• ��� Lic CCllasX -�� swim I�1G P ,l DATE C/
���,.� G 1. sP _1L ��oZ� Ln L , ®J 0". o 9 a 3'6'05',
Contractorr /"K/4� Date }
SQ FT C-
a' I am exempt under Sec SIZE . f Y ;� (�2;� C 8 8 O
B 8P.C-for this reason ELECTRICAL-
0
Date
Steel'&Conduit Bonding ( 0 94 5 A w
Signature Conduits, Conductors, Equipment' 'j
SINGLE FAMILY `#'0 0 a•o X 0 3
HOME OWNER-BUILDER DECLARATION PLUMBINGi - Z
I hereby affirm that I am exempt from the Contractor's License c i ' ' , ,i ! 0'3, Q 2 6
Law.for the follovvmg reason (Section 7031 5, Business and �n 0 0'3'1 4.2 6 cy�
Professions Code)' P-Trap
Gas System !�
I,'os owner of the property, will do the plumbing and Anti-Syphon _ f-� Q-2)� -•$8
electrical work 1,or my employees with wages as their
sole compensation,or a licensed,contractor will do all MECHANICAL
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code) Swimming Pool Heater
CONSTRUCTION LENDING AGENCY t '
I hereby affirm that there is a construction lending agency for APPLICANT ,/
the performance of the work for which this permit is issued (PRIN / �^T� W4 p
(Sec 3097, Civ C )
Lender's Name ADDRESS ^ L
Lender's Address el,' - 5, d 3•**•7,6
(�
I certify that I have read this application and state that the P C Fee b Permit Fee
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
representatives of this County to enter upon the above- Total Fe / yj
toned p y r inspection purposes
ignature o Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE