HomeMy Public PortalAbout6007 MUSCATEL AVE_Swimming Pool__ . W4ORKERb'COMPENSATIClN DECLARATION �y
'hereby'affirmI'hot I have a certificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, :.r a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.) . 76A20B
4 ' CE876(3/84)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
E] Certified copy is hereby furnished.
OBUILDING
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS �
tion department. BUILDING
ADDRESS A 60'7 LOCALITY
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' [TRAC
ITY �F. ZIP CROSSOR
COMPENSATION INSURANCE SIZE OF. _�/ ASSESSOR
T� ('�_ J LOT r✓/ /�I I b LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit Is for one n TEL. p USE Z NE MAP
hundred dollars($100)or less.) OWNER/ lZNO.�O —G g� NO.
I certify that in the performance of the work for which this �l I SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS (p 8� ! CONDITIONS
so as to be ome subject to the Wo kers'Compensation Laws. / /y DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
_r},a� CITY /y! Cts L.L ZIP CLASS Npt�f/ CONST. `///"►/(//
Dat Applicant(py' •/�V� ARCHITECT OR TEL. U'2 1/7
NOTICE TO PPLICANT: If, after making this Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS `�6ro VALID ION
with comply with such provisions or this permit shall be TEL. $ vV IV
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.LIC. $
(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 DATE P10 ® a:
1 d
Contractor Date SPA ^ � FINAL t 0
❑ SQ. FT. vl`
I am exempt under Sec. SIZE BY { Q-0
I O
B.&P.C. for this reason ELECTRICAL
Date:
W
Signature Steel &Conduit Bonding C'
g Conduits, Conductors, Equipment N
SINGLE FAMILY Ea� Z
HOME OWNER-BUILDER DECLARATION PLUMBING #0 6 4 7(e
I hereby affirm that I am exempt from the Contractor's License 44
Law for the following reason (Section 7031.5, Business and P-Trap o 0 3
0
Professions Code): Gas System 0206-87
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 ;E 6 4 7. 7 A
other work and the structure is not intended or offered '0 0 0 0 0�
for sale Section 7044 B&P Code). ° 6 a,A
( ) Swimming Pool Heater o ° ,� 6��6=
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TEL. � L G 6--A
the performance of the work for which this permit is issued (PRINT) NO
(Sec. 3097, Civ. Com�.,)�. //99�,,��4y �/J
Lender's Name�f�R ADDRESS VV //!(�Q S 4
Lender's Address 3f 7 6
P.0 Fee$ n� PermFee
1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County J O �v
ordinances and State laws relating to building, electrical, Issuance Fee r
mechanical and plumbing construction,and hereby authorize Investigation Fee r
representatives of this County to enter upon the above- Total Fee �J
mentioned property for inspection purposes.
4f. m,14=.9- _2
Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE