HomeMy Public PortalAbout5010 MCCLINTOCK AVE_Swimming Pool__ 1 (
WORKERS'COMPENSATION DECLARATION ~ 1. Gtr AqW ' •�J7
hereby affirm that I have r certificate of consent to self i APPLICATION FOR COMBINATION SVIII MING POOL PERM1T
insure, o11r{{a certificate of Workers'Compensation Insurance,
oT VVEd�a�a�b hiec. 3800, Lab. C.) �6A20B
422$5, E-875(11/81)
Policy No. company Travelers Ins. ? COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. BUILDING
® FOR APPLICANT TO FILL IN ADDRESS CSL L�7r0
Certified copy is filed with the county building inspec- ADDRESS ��
tion department. BUILDING
9-14-83 Anthonyools ADDRESS 5010 McClintock Ave. LOCALITY 1- C•ie&
Date Applicant y
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY Temple City ZIP 917$0 cRQSs ST.
COMPENSATION INSURANCE ASSESSOR
TRACT 13384 LOT SIZE OF LOT NO. 2 MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one TEL. USEIZONE MAP
hundred dollars($100)or less.) - OWNER MUrra .. Billy Jo NO. 442-3201I NO.
I certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS 5010 McClintock Ave. , �� CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY Temple City zip 91780 CLASS NO. CONST.
Date Applicant ARCHITECT ORR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER K. J. Kolodziej NO. 268-4$77 IV
Exemption, you should become subject to the Workers' ,VALUATION
Compensation provisions of the Labor Code, you-must forth- ADDRESS 4900 Triggs St. Cit of Commer e ,
with comply with such provisions or this permit shall be TEL. $ VALIDATION.
deemed revoked. CONTRACTOR Anthony Pools .NO. 26$-4$77 10,395.00
LICENSED CONTRACTORS DECLARATION riggs: . LIC.
ADDRESS City C NO.190179
1 hereby affirm that I am licensed under provisions of Chapter 9 LIC. $
(commencing with Section 7000) of Division 3 of the Business rr1 CITY City of Commerce 90022 CLASS C53 >.
and Professions Code,and my license is in full force and effect. I3.
DESCRIPTION OF WORK
License Number #190179 Lic. Class C53 SWIMMING POOI7f� � �'X� "� � jDATEFINAL
/� `fes- ,t` , - 5 5 0.2 A tj
contractor Anthony Pools Date 9-14-83 I � ' J J ' �INAL i ` ° " ° 2 1 O
SQ. FT. BY +,'a tl...� U
El am exempt under Sec. I SIZE 450 I 2 u - 73.64 LU
B.&P.C. for this reasoni o 0 7 3,'6 Ll,
Date: CZ,DELETE B 0 9,2 2--8 3
Signature
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business•and P-Trap
Professions Code): Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I,or my employees with wages as their " r' 6 0 3 A
sole compensation,or a licensed contractor will do all I MECHANICAL
other work and the structure is not intended or offered 3
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY 2 - 25700
1 hereby affirm that there is a construction lending agency for APPLICANT
the performance of the work for which this permit is issued TEL' 011.
o , 2 c / C 0
P P (PRINT) AnthonyP001S NO 268-4877
(Sec. 3097, Civ. C.). ,
Lender's Name CASH ADDRESS 4900 Trl s St C I 0 922-83
Lender's Address
y' 3 Gj
I certify that I have read this application and state that the P.C.Fee$ Permit Fee
above information is correct. I agree to comply with all County
ordinances an4 State laws relating to building, electrical, Issuance Fee �,>30
mechanics plumbi co truction,and hereby authorize Investigation Fee
represen ti s of th' ty to enter upon the above- Total Fee
�g (�t�
menti roperty r i 'on
Anthony Pools 9-14-83
Signature of Appl' a or Agent Date I SEE REVERSE FOR EXPLANATORY LANGUAGE
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