The URL can be used to link to this page

Home My Public Portal About5019 MCCLINTOCK AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION Thereby affirm that I have a certifi a of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT infteor a certificate of Workersom ensation Insurance}�d�Q�.lt• ereof(Sec. 3 0, b. C.)g'✓er I J� cE8798(11/81)Company COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby fu ni e . •. FOR APPLICANT TO FILL IN BUILDING �l41 Wert led co y is filed wit e.co �inspec- ADDRESS lJ ti de r nt. BUILDING ADDRE LOCALI Date Applicant � NEAREST CITY CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKER ' SIZE OF ASSESSOR COMPENSATION INSURANCE MRR LOT LOT NO. MAP BOOK PAGE PARCEL (This section need not be completed if the permit Is for one TEL. USE ZONE MAP' hundred Ilars($100)or less.) NO. I NO. CJ I certify tha ' the performance of the work for which thisQQ ��]/�/ / SPECIAL permit is issue shall not employ any person in any manner 9 / ° �V CONDITIONSso as to become s 'ect to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPEPROCE ED BY IP ` CONSTDate Ap ant TEL. J/j� ! ,U CLASS NO `1NOTICE TO APPLICANT: If, r making this Certificate of NO Y v (rJ Exemption, you should beco subject,to the, Workers' VALUATION Compensation provisions of the La Code, you.must forth- ADDRESS/Mk—R6 with comply with such provisions o his permit shall be $ ] !1/b— VALIDATION deemed revoked.' CONTRA N f (J(J LICENSED CONTRACTORS DECLARATION ADORES �Z/v I hereby affirm that I am licensed under provisions of Chapter 9 LIC $ (commencing with Section 7000)of Division 3 of the Business V } and Professions d nd y.i e e is in full force and effect. CITY SS DESCRIPTION OF WORK FINAL V License Number Lic. Class SWIMMING POOL Dr DATE ► = 0 2 5 L4 A SPA r 9W` FINAL J o 0 0 o 2 1 0 Coniracto SQ.FT. qJ O BY _ , � � U 1 am exempt under Sec. SIZE- 2 Fo t o 7 3 h 4 It B.&P.C. for this reason �• i 6 s ELECTRICAL ^'�I`o'•% �4 c• • Date: t Signature Steel 8 Conduit Bonding 0 0.r1—8f4 Conduits, Conductors, Equipment SINGLE FAMILY f HOME OWNER-BUILDER DECLARATION PLUMBING I hereby affirm that I am exempt from the Contractor's License �' t' - Law for the following reason (Section 7031.5, Business and P-Tram lam/ Oe .- A Professions Code): Gas SysteI✓! 11 C F010 0 0 w3 I, as owner of the property, will do the plumbing and Anti-Syphon ' electrical work. I,or my employees with wages as their. 2'-'2 5?, 00 sole compensation,or a licensed contractor will do all MECHANICAL other work and the structure is-not intended or offered• 0 0 i ?, 0 V for sale (Section 7044 B81P Code). Swimming Pool Heater CONSTRUCTION LENDING AGENCY ( 0 C 5—8 4 1 hereby affirm that there is a construction lending agency for APPLICANT TE the perform"ce the work for which this permit is issued (PRINT) N (Sec. is N / Lender's Name , t Lender's AddressG' P.C.Fee$ rus' Permit Fee LJ I certify that I have read this application and state that the I,w above informatio, co rect. I agree to comply with all County l� , [ordoinas State aws relating to building, electrical, Issuance Fee plum ngconstructionndhereby authorize Investigation Fee (�oft County to en r on.the above- Total Feee or inspection r e . _` (SJ( ignature of Applicant orOnt- Date SEE REVERSE FOR,EXPLANATORY LANGUAGE `WORKERS'COMPENSATION DECLARAT L�:.., here"k3q affirm that I have a certificate of content to self or a certificate ofAPPLICATION FOR COMBINATION SWIMMING POOL PERMIT uWorke C�Qmpensafion InsuratSce, � or ertif'ed c ereec Q Lab. 7 2t)B j CE 75(11/81) RSRw Pany COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. l _" ` v ADDRESS C(.I �.70� Certified copy is filed with ount building inspec- FOR APPLICANT TO FILL IN ADDRESS C K. tion depart t. BUILDING j �� .r `r` ADDRESS I J /OLLR2�. LOCALITY +971 FL4 Date � ApplicantNEAREST CERTIFICATE OF EXEMPTION FROM WORiJ E CITY ZIP CROSS ST. COMPENSATION INSURANCE `` SIZE ASSESSOR TRACT I� LOT LOT NO MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one 1►r TE USE ZONE MAP hundred dollars(;100)or less.) OWNER"""' 1412aN /� NO. I certify that in the performance of the work for which this �� + _ /rLr+,s� SPECIAL permit is issued, I shall not employ any person in any manner ADDRES ` CONDITIONS so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY C� C L ZIP CLASS N CONST. Date Applicant ARCHITECT� �f L �� TEIa G�7�1(� j y� NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER `1 ► 4J�3-.a �/ �"' Exemption, you should become subject to the Workers' ADDRESS U10 VALUATION 'Compensation,provisions of the Labor Code, you.must forth- /)r VALIDATION with comply with such provisions or this permit shall be CONTRACT f(/v TEL $ deemed revoked. J / 1,666 LICENSED CONTRACTORS DECLARATION ADDRE J �r NC J I hereby affirm that I am licensed under provisions of Chapter 9 $ hereby with Section 7000 of Division 3 of the Business / LIC' and Professions Code,-and my license is in full force an effect. CITY UUP CLASS _Q I O DESCRIPTION OF WORK I�-1ry .FINAL , License Numbe V Lic. Class SWIMMING POOL ilk DATE U Contra.ta ate SPA / / FINAL 1 6 2.8 A 0 i SQ.FT. By U r_1I am exempt under Sec. SIZE o o °'0 2 1 y B.&P.C. for this reason ELECTRICAL 2 ° ° 7 6 4 Z ,Date: :°Yo ° 7 3 6 4 Signature Steel Conduit Bonding I Co duits, Conductor , Equipment SINGLE FAMILY 0 E O 2-.8 3 • HOME OWNER-BUILDER DECLARATION PLUMBING , z 1 b 20 A 1 hereby affirm that I am exempt from the Contractor's License GG Law for the following reason (Section 7031.5, Business and P-Tropa� o 0 0 0 go 3 Professions Code): Gas System I, as owner of the property, will do the plumbing and Anti-Syphon -2'- 257.00 electrical work. I,or my employees with wages as their sole compensation,or a licensed contractor will do all MECHANICAL ro 0 257,0010 other work and the structure is not intended or offered for sale (Section.7044 B&P Code). Swimming Pool Heater ] 0.5.02-83 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for APPLICANT TE the performance of the work for which this permit is issued (PRINT) NO. (� (Sec. 3097, Civ. Lender's Name I ADDRESSX44:22 (,J Lender's Address P.C.Fee$ Permit Fee I certify that I haver this application and state that the above information is corre I. I agree to comply with all County r?1 opntione nd tate la s relating to building, electrical, Issuance Fee nd umbin construction,and hereby authorize Investigation Fee res ounty to enter upon the above- Total Fee Cliorop ty f spection purposes. Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE