HomeMy Public PortalAbout5402 LOMA AVE_Swimming Pool__ ' WORKERS' COMPENSATION DECLARATION
I•hete,o affirm that P have "r ce' Cernp,nsation Insurance"selft APPUCAM)ICJ •�DR CORBONA7ODH SWMb90N POOL
PERMIT
insure, or a,'certificate of Workers' Cd'm ensahon Insurance, B �f" ((�•'f�Jy '
or a ce!4ified copy thereof (Sec 3800, Lab C ) 76A208
CF876(3/84) -
Policy,No Company COUNTY OF LOS'ANGELES BUILDING ARID SAFETY '
Certified copy is hereby furnished"
BUILDING'
Certified copy is filed,with the'county building mspec- FOR,"APPLICANT`TO FILL IN. - ADDRESS
.flan department - BUILDING „��pp ,
ADDRESS DSV( LOCALITY G�
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS CITY _M r^i” ZIP 7.( D CROSS ST O`
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO MAP BOOK PAGE PARCEL
(This section need not be completedhe if tpermit is'for one -TEL USE ZONE MAP
hundred dollars ($100)or'less.)'" {` " ' OWNER V NO NO
I certify that in the performance of the work for which this SPECIAL r
permit is issued, I shall not•employ any person in any manner ADDRESS, CONDITIONS-
so as to become subject to,the Workers'Compensation Laws DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP l V ,' ;� CONST, -
_ _ _ =CLASS NO •
Date' Applicant ARCHITECT O TEL 19, 'k a �/ '
NOTICE Tb-'APPLICANT If;,'after-mokirig this,Certificate of ENGINEER + NO //�T s /n esti
Exemption, you should become subject to the Workers" � VALUATION
-p
Compensationrovisions'of the Labor Code, you must forth- ADDRESS ��
with comply with;such provisions;or this permit,shall be _ - •TEL` $ S/ &.Q VALIDATION
deemed,revoked CONTRACTOR NO
LICENSED CONTRACTORS DECLARATION - LIC '
ADDRESS NO
I hereby ciffirm that,I am licensed under provisions of Chapter 9 LIC $
(commencing with,Section 7000),of Division 3 of,the Business CITY CLASS'
and Professions Code,and my license is in full force and effect
DESCRIPTION OF WORK FINAL _
���'
License DAT Number G Lic Class ' SWIMMING POOL i'
Contractor f Date SPA FINAL tti�p JL
SQ FT F'I( t o S V
r m BY (/` - �y
❑1 I dm exempt under Sec SIZE �OD +VI y� 13^j.4
B&P C' for this reason ELECTRICAL K 4 ITEMS -
Date
TOTAC 137
" e Steel &Conduit-Bonding
Stnatur
'
9 Conduits' Conductors, Equipment ®,. "CHECK Ito4�2
SINGLE FAMILY
-BUILDER DECLARATION CHANGE HOME OWNERe�f
1 hereby affirm that I am,exempt from the Contractor's License.
Law for'the following`,reason (Section 7031 5, Business and - v' `•
P-Trap'
Professions Code)
,x. Gas,S stem `t C
I, as owner of the property, will do the plumbing and Anti-Syphon —C �' _i
electrical work 1,or my}employees with wages as their _ 2846 1 AN 3*It ,
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
I hereby affirm that there is a construction lending agency for APPLICANT TEL ooyyccpp
the performance of t_he,Aork for which this permit is issued (PRINT) I�J?ww NO
(Sec 3097„ Civ C )
CJ �
Lender's Name ADDRESS'
Lender's Address -4
PC Fee$ Permit Fee - '
I certify that I have read this application and state that therri
66 yy
above information is correct I agree to comply with all County
ordinances and State laws relating,to building, electrical, Issuance Fee p, dry t
mechanics,and u ng construction, and hereby authorize Investigation Fee
represe ves t s County to,enter upon the above- Total Fee «-
mentio d o ns on purposes .
Signature f Ap hcant or Agent Date SEE REVERSE FOR EXPLANATORY LANbLOGE