HomeMy Public PortalAbout6412 OAK AVE_Swimming Pool__ WORKAR')V MpEt.JATI0N DECLARATION
I�oreby of certificate
fI hove o certificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERU'��T
insdifa, or a certificaica te nr Workers Compensation Insurance,
o.,tr a r'fled copy thr eof (Sec. 3800, Lab. C.) 7sn2oB
�9 � , p A CE876(3/84)
Po icy o.1 — - Company N`�Yy� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified co is filed with the count building p FOR APPLICANT TO FILL IN BUILDING /J
PY y gins et- ADDRESS //
tion department. BUILDING 104j_4 MV
ADDRESS
DoreC)Rw Applicant �- LOCALITY
NEAREST _ )
CERTIFICATE OF EXEMPTION FROM WORKERS'17 r CITY _ ZIP CROSS ST. 'lJ
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed IF the permit Is For one TEL. 44-1+� USE FE,
MAP
hundred dollars($100)or less.) OWNER NO. NO.
1 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 CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CLASS NO. CONST.
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. 65
J
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS VALIDATION
with comply with such provisions or this permit shall beTEL. $ ��o
deemed revoked. CONTRACTOR NO. E
LICENSED CONTRACTORS DECLARATION ADDRESS tr>&T IC• l IOZ
I hereby affirm that I am licensed under provisions of Chapter 9 $
(commencing with Section 7000) of Division 3 of the Business LIC.
CITY {�, CLASS(j
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
License Number'TT'�� Lic. Class FINAL
n�AA�(� S� SWIMMING POOL � DATE
Contractor ADate%10' SPA (/aF ® FIN Q
SIZ FT.
I am exempt under Sec. SIZE
100
Q.
for this reason ELECTRICAL �.
Date: t1J
Signature Steel &Conduit Bonding N
Conduits, Conductors, Equipment
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING 9 O 3 9 A
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and I,? 0 0 0 0 201
Professions Code): P-Trap
Gas System I ° 1 011.5 3
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I,or my employees with wages as their ° ° 1 C 1.5 c=i
sole compensation,or a licensed contractor will do all MECHANICAL ,.
other work and the structure is not intended or offered G C 4—
for sole (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY P,
I hereby affirm that there is a construction lending agency for APPLICANT TEL.
the performance of the work for which this permit is issued (PRINT) NO. }e o 0 0 0 0 T.
(Sec. 3097, Civ. C.). , l'1
Lender's Name 1,/N�VDADDRESS EM92 9-7. Lt lkGf. I ° ;,O 1,
Lender's Address /� 0 �• <
I certify that I have read this application and state that the P.C.Fee S C I �3 Permit Fee f '
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee V
mechanical and plumbing construction,and hereby authorize Investigation Fee
representatives of this County to enter upon the above- Total Fee
mentioned rty for inspection purposes.
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Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE