HomeMy Public PortalAbout6467 LIVIA AVE_Swimming Pool__ %jam+ WOOERS'6O;fIPENSATION DECLARATION p"(� rip" 5� �p pip (�s(� [� p 2®®�
I hereby affirm certificate
laver certificate Compensation
of consent to self -APP B AT10H FOR
C'®I1CN��II�JA MN SVvB11CTll�q MIG POM P115@ntii�N��
insure, or a certificate of Workers' Com ensation Insurance, Il'l6 @y IlV u W k1�/IJ
or a certified,.copy thereof (Sec' 3800_, Lab C-) 7sn2oB - .: w' ' '
11
���//' yy f 1�� ^ 1 ^ CE876(3/84)
Polic�No�� /��`�' Company _ w' 4 COUNTY OF LOS ANGELES BUILDING AND`SAFETY
Certified copy is hereby furnished
BUILDING
Certified copy is filed'with the county building-inspec- -FOR APPLICANT TO FILL IN - ADDRESS
tion department BUILDING UH((_ /;
ADDRESS �J� I V•I (/�� �^'L_' LOCALITY T °
Date ILI Z� - Applicant v 1 7T� NEAREST
CERTIFICATE OF EXEM ON FROM WORKERS'- CITY�� ZIP {�- V CROSS ST
1 SIZE'OF ASSESSOR
',COMPENSATION INSURANCE } + TRACT LOT LOT NO MAP BOOK PAGE PARCEL
(This section need not be completed If-the perml't is for one TEL �j1 USE ONE MAP
hundred dollars($100)or-less.) • OWNER D1'1� 1^ 7 Z NOd r, 7~1D�� NO
I certify that m the performance of the work for which this* 1 . 7 1 'SPECIAL o
permit is issued, I shall not employ,any person in any manner ADDRESS ',v rV u -e__ i CONDITIONS
so as to,become subject to the Workers'Compensation Laws tib% �J 1)t DISTRICT TATISTICAL CLASS TYPE PROCESSED BY
CITY /Y� �� ZIP / ! ,/ 'CONST
Date Applicant os ARCHITECT OR TEC���,�7 r)f '' CLASS-NO
NOTICE TO APPLICANT If;'after-making this Certifica'te'of
ENGINEER �� D ,' NOy� / J
Exemption,- you should become subject to the Workers':' � VALUATION ;
'Compensation provisions of the Labor,Code, you`must forth- ADDRESS. ( l�
TEL21 VALIDATION
with comply with such provisions or ,this permit shall be $
(C (!}(
deemed revoked CONTRACTOR 1�n ��J NO � ��
LIC
LICENSED CONTRACTORS DECLARATION gDDRESS�!`� `Tp ( Is— NO �a�'1
I he 11 affirm that I am.licensed under provisions of Chapter 9 LIC $ - �8 8.2 6 A
(commencing with Section 7000) of Division,3 of the Business CITY �' /,ln/�� CLASS C�,
and Professions Code,and my license is m full force and ect DESCRIPTION OF WORK # °,o 0 02
I ( °.1 3J S O O }
License NumberLic Cldss SWIMMING POOL DAT [/
Contract o 4r��11 DateSPA
:, ' '`� �V FI L - ° ° '3 0 Q U U
/ SQ FT
I am exempt un e Sec SIZE -�' t' 0 �.2 2,"8 8
C for this reason O
B&P
- y ELECTRICAL' U
Date
c 0..
Si nature - Steel'&Conduit Bonding - =': i y' V)
9 Conduits, Conductors, E ui merit ,
SINGLE.FAMILY, •. 9 P - • ;28 8 27'A z
HOME OWNER-BUILDER DECLARATION' PLUMBING
1 hereby offirm'that'I'am exempt from the Contractor's License `X,;.
'Law for the following reason (Sectiori,7031 5, Business and ,4 6'4 2 6
Professions Coe) GTrap
d
Gas,System ,
I, as owner of the property, will do the plumbing and Anti-Syphon " s.e 11 64,2 6 5
electrical work I,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 11. 8
for sale (Section 7044 B&P Code) Swimming Pool Heater S -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
APPLICANT C TEL 7
the performance of,the work for which this permit is issued (PRINT) `I � � NOJ� �Q
(Sec 3097, Civ C
.,Lender's Name ADDRESS LJ
.Lender's Address f"
PC Fee$ J l`�V Permit Fee ,
I certify that I have read this application and state•that the f _
above information is correct I agree to comply with all County Issuance Fee 10 O
ordinances and State Jaws relating to building, electrical,
mechanical and plumbing construction, and hereby authorize Investigation Fee -
representatives of this County to enter upon the above- Total Fee N I t
ntio ed property for i spection purposes
Signature'of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE