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HomeMy Public PortalAbout5442 LOMA AVE_Swimming Pool__ N!ORIZERS' COMPENSATION bECLARATION I hereby affirm that I have r certificate of consent to self /�P p C n MN FOR C®61N PHA Il EDN c�VC/�11171IfIn MIG POOL PER111y11� 6 insure, or a certificate of Workers' Compensation Insurance, /nll!"IT l6 6'9 U Q or a certified copy thereof (Sec 3800, Lab C ) 76A2oe CE876(3/84) -Policy NaZtl !E 'CoinpcmySYA- 1-e rte/ COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING "Z !_o Certified copy is filed with the county building spec- ADDRESS m tion department BUILDING Date A ficant �_ ADDRESS 7 © LOCALITY �a .3/ 9 PP �— CITY J^e/YN C ZIP CROSSST CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE r SIZE,OF ASSESSOR TRACT LOT - LOT NO MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one L�?? TEL USE ZONE MAP hundred dollars($100)or less.) I I OWNER cJ/ r NO NO I certify that in the performance of the work for which this SPECIAL ���e�58�9 permit is issued, I shall not employ any person'in any manner ADDRESS p CONDITIONS so as to become subject to the Workers'Compensation Laws DISTRICT STATISTICAL-CLASSTYPE \ PROCESSED BY CITY ZIP ' ' Date Applicant ARCHITECT OR TEL CLASS NO CONS NOTICE TO APPLICANT If, after making 'this Certificate of ENGINEER NO 3 ►Q2 O� 3' Exemption, you should become subject to the•Workers" AA VALUATION Compensation.provisions of the Labor Code, you must forth- ADDRESS 2� A 497- �' VALIDATION with comply with such provisions or this permit shall be CONTRACTOR ,7440 $ deemed revoked ca� LICENSED CONTRACTORS DECLARATION ADDRESS NO'� I hereby affirm that I am licensed under provisions of Chapter 9 LIC $` (commencing with Section 7000) of Division 3 of the Business I CLASS and Professions Code,and my license is in full force and effect DESCRIPTION OF W s FINAL' License Numbergig<<g Z Lic Class SWIMMING POOL' M� DATE Contractor""dt1 �� Date � -�J� ��Q SPA I`�I e FI / R E] SQ FT gy I am exempt under Sec SIZE 0- B&P C for this reason ELECTRICAL U Date ® - W Steel 8 Conduit Bonding 0_ Signature Conduits, Conductors, Equipment v — N SINGLE FAMILY ° ? HOME OWNER-BUILDER DECLARATION PLUMBING I hereby affirm that I am exempt from the Contractor's License _ _ D (: •? �s Law for the following reason (Section 7031 5, Business and Professions Code) P-Trap Gas System j, as owner of the property, will do the plumbing and Anti-Syphon t €TErS electrical work j, or my employees with wages as their sole compensation,or a licensed contractor will do all MECHANICAL T 6(;-1L 15:3 - 00 other work and the structure is not intended or offered f' f:}, for sale (Section 7044 B&P Code) - Swimming Pool Heater - CONSTRUCTION LENDING AGENCY •_H4)'GEoLi I hereby affirm that there is a construction lending agency for APPLICANT TEL the performance of the work for which this permit is issued - PRINT NO (Sec 3097, Civ C )( ) D [H Ci l�l—ti)i fl, Lender's Name ADDRESS Lender's Address - 3 ti PC Fee$ Per Fee I certify that I have read this application and state that the above information is correct I agree to comply with all County `!� c7 \ if_!•�e&s ordinances and State laws relating to building, electrical, Issuance Fee v JLJ _ _ , mechanical and plumbing construction, and hereby authorize Investigation Fee o�t' representatives of this County to enter upon the above- Total Fee `J — entioned erty for inspection purposes !T-1'- Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE _: a 0 1Q