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HomeMy Public PortalAbout5232 MCCLINTOCK AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION + l I hereby 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(Sec. 3800, Lab. C.) .,s, 76A20B c y , M" I CE-875(11/81) Policy No.� Z&_-tkompany ��� jIVS. �ROK�e COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is hereby furnished. BUILDING / Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN' ADDRESS ���.•' � � /} Tion department. BUILDING G A� ADDRESS ��� �C'Gl�Toc c �C. LOCALITY Date Zot 3-83 Applicant 121441M1 F"4- 4 s NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' I CITY �TEMPLC G/Ty ZIP CROSS ST. COMPENSATION.INSURANCE 13; '�� SIZ F ASSESSOR TRACE LOT�,� �7 0 N0. r MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one p� TEL. �p,f ��y/ / USE ZONE OP r+-- hundred dollars(:100)or less.) OWNER /1C s rj(�I E/Q�QC k No. C ¢ I certify that in the performance of the work for which this C n SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS 5 2 3 Z —Cgw rack ?tJ • CONDITIONS so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE T PROCESSED BY CITY 914 SL E (fir ZIP � CLASS NO. T� _ Date Applicant ARCHITECT OR /� TEL. 9 j NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER �iL,i �� NO. �36��L9 O©� � �/� Exemption, you should become subject to the Workers' ADDRESS j��s VALUATION Compensation provisions of the Labor-Code, you.must forth- I �RAoKH+�R C,AROJJtI G/L0 O 0 VALIDATION with comply with such provisions or this permit shall be A� TEL. ; /� �Q deemed revoked. i CONTRACTOR I AYIPS Pao G/�ST,.NO. a2. e LICENSED CONTRACTORS DECLARATION 4 p W EELS J ft D� LIC. ADDRESS JL . NO. e , I hereby affirm that I am licensed under provisions of Chapter 9 LIC $ (commencing with Section 7000) of Division 3 of the Business CITY i •4 Will C� CLASS e and Professions Code,air (icense is in f II f rce and effect. DESCRIPTION OF WOR �I— ,/ FINAL �� may.,, , V /LLicese Number �3i s �� � SWIMMING POOL �' � LJ DATE /G/ `'j�['„�ractor//,�L/N� �0OIL ate ��"/�`o , SPA �y R_ FINAL � j . , V ❑ 11— SQ. IT. 2 ✓ TO%AL BY �' {i'�^' i2 F 9 a F p, IL I am exempt under Sec. SIZE !. ` B.&P.C. for this reason ELECTRICAL' 4 o 0 0 0 2 1 Z. ��~� ��� Date: /� 7 0 0 7 9,2 1 Steel &Conduit Bonding `y Signatures' ' Conduits, Conductors, Equipment ❑ r" s I SINGLE FAMILY _ °iO ° 7 Q.2 1 HO OWNER-BUILDER DECLARATION �~ PLUMBING 1 hereby offI that I am exempt from the Contractor's License 10. 1 6.--313. Law for the following reason (Section 7031.5, Business and P-Trap , 1 F 9 h Professions Code): Gas System v • I, as owner of the property, will do the plumbing and •. Anti-Syphon ; 0 a a o 0 3 electrical work. I,or my employees with wages as their , . sole compensation,or a licensed contractor will do all MECHANICAL .o r 7 it 2 6 other work and the structure is not intended or offered for sale (Section 7044 B&P Code). Swimming Pool Heater Q Ic o 2 7 6 2:6 CONSTRUCTION LENDING AGENCYI ,I jLA 1 4-83 . I hereby affirm that there is a construction lending agency for APPLICANT C- TEL• 71� the performance of the work for which this permit is issued (PRINT) DL/A/ ONd(Sec. 3097, Civ. C.). ® Z$_/ 3/ 0. , Lender's Name ADDRESS T / 7 JRJa& / C j4/JV0 i Lender's Address P.C.Fee$ �J"�-1 Permit Fee � /� og I certify that I have read this application'and state that the , above information is correct. I agree to comply with all County ordinances and State laws relating to building, electrical, Issuance Fee • mechanical and plumbing construction,and hereby authorize Investigation Fee epresentatives this County to enter upon the above- Total Fee 6.1 ntioned pro rt for'nspection purposes. Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE