HomeMy Public PortalAbout6448 LOMA AVE_Swimming Pool__ W ?CERS'COMQENSATION DECLARATION t
I.h�,eby affirm that I have a certificate of consent to self
insure, or a.certificate of Workers' Compensation Insurance, . APPLICATION, .FOR )COMBINATION SWIMMING :POOL PERMIT
or a,certified copy thereof(Slee.'3800, Lab. C. 76A20B
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SA ETY
Certified copy is hereby furnished.
BUILDING
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS 14 LN tet�_ ulloq
tion department. BUILDING (144-F71 �-Ot-"Ifs ��lG LOCALITY
ADDRESS
Date ApplicantNEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITYR� ZIP �� � CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LO_ T LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one TEL. USE ZONE MAP
hundred dollars ($100)or less.) OWNER EVA-r NO.287_74'_71 NO.
I certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not emIrkers
y pI o ' any manner ADDRESS wv�Q�7 �1 .�—df II' t�s r CONDITIONS
so as to become subject to the 'Oolnpe i S. DISTRICT STATISTICAL CLASS TYPE PROCESS '8Y,
//j`c>7 ZIP � I7� Q CONST.
Dat t v Applicar CHITECT TEL. CLASS NO. e
NOTICE TO APPLICANT: If, after making this Certificate ENGINEER "SLY 1-Ubp�� NO.Ap�4,G`R�
Exemption, you should become subject to the Workers'" ADDRESS ��[1 t1-YVV LQC_t-uJI(�. VALUATION
Compensation provisions of the Lobar Code, you must forth- VALIDATION
with comply with such provisions or this permit shall be TEL. S
deemed revoked. CONTRACTOR �*crrr� NO.
LICENSED CONTRACTORS DECLARATION LIC.
ADDRESS NO.
_ I hereby affirm that I am•licensed under,provisions of Chapter 9 LIC. $ �r
(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 Number Lic. Class SWIMMING POOL DA
SPA .. - ,.
Contractor Date II / Q
❑ SFT. gy
lam exempt under Sec. SIZE
E
B.&P.C. for this reason ELECTRICAL �+ O
Date: / r 6 A W
Si nature Steel & Conduit Bonding n-
9 Conduits, Conductors, Equipment LYJ ( o 0,0 a o Z
SINGLE FAMILY J ° ° 8 9,2
HOME OWNER-BUILDER DECLARATION PLUMBING I
I hereby affirm that I am exempt from the Contractor's License I ° °'° 8 9.2.6 6.
Law for the following reason (Section 7031:5, Business and P-Trap ,
Professions Code): Gas System ® 0•1. 3"86
I, as owner of the property, will do the plumbing and Anti-Syphon
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
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.
I the performance of the work for which this permit is issued (PRINT) 47-W--k�l NO. ZS77W_7
I: (Sec: 3097; Civ.'C.).
Ii Lender's Name ADDRESS %V'-J
1 Lender's Address
P.C. Fee$ Permit Fee
i I certify that I have read this application and state ll that the �-
above information is correct. I agree to comply with aCounty V
ordinances and State laws relating to building, electrical, Issuance Fee
j mechanical and plumbing construction, and hereby authorize Investigation Fee all2
Jr
representatives of this County to enter upon the above- Total Fee 15
ntioned r peri for inspe ion purposes.
(
ISignature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE