HomeMy Public PortalAbout5344 PARMERTON AVE_Swimming Pool__ WORKERS COMPENSATION DECLARATION
hereby affirm that shave a certificate of consent to ,elf APPLICATION FOR COMBINATION SWIMMING POOL- PERMIT
ifisure or o certificate of Workers Com ensanon Insurance, - •
or a cert d copy thereo Sec 3800 C ) i 76A20B , x :- -. . -
CE676 t3/Bal
Fohcy "�E mpany Okd4k _ I ' — COUNTY OF LOS ANGELES BUILDING AND SAFETY _ E
Certified copy is hereby furnished ' {
ernfied copy is filed with the 1ounry wldmq rnspec ` FOR APPLICANT TO,FILL N - - BUILDING
hon depart tit BUILDING - 7
ADDRESS y 4. r 0I - LOCALITY-7,0 - u
Data Applicolt NEAREST l
CERTIFICATE OF EXEMPTION FROM WORKERSU, CITY FNM Cha _ -ZIP_'_ _ _ _ CROSS ST f
COMPENSATION INSURANCE SIZE OF Y ASSESSOR s
TRACT LOT LOT NO MAP BOOK PAGE PARCEL
(This section need not be completed If the permit Is for one TEL USE ZONE • MAP
hundred dollars($100)or less ) • tc OWNER A//ACIa- NONO
I certify that in the performance of the work for which this /� �� 3 SPECIAL .. .
permit is issued I shall not employ any person in any manner ADDRESS / v-/� �l CONDITIONS ,
.so as to become subject to the Workers Compensation Laws -' , ^ DISTRICT STATISTICAL CLASS TYPE+ - SSED BY
ffi CITY ZIP " CONST a ,
Date Applicant �� _ ARCHITECT TEL CLASS NO
NOTICE TO APPLICANT If after making this Certificate of ENGINEER /7J N01Q�D(Vy
Exemption you should become subject to the Workers ` r. ' VAWA710N -
Compensation provisions of the Labor Code you must forth ADDRES 19 �`� • ��• t4
with comply with such provisions or this permit shall be I+ ,7EL S ) VALIDATION
deemed revoked CONTRACT jOjl" Z �, 3 Oo8 E
LICENSED CONTRACTORS DECLARATION t ADORE N' 1 LIC
,I hereby affirm that I am licensed under provisions of Chapter 9 CI LIC 2u Y-! LIC •, $` - e• - 't
(commencing with Section 7000) of Division 3 of the Business - `•'
and Professions Cod and my license is in full force and effect ,
/^•�� DESCRIPTION OF WORK �FINAL � {• S L
Li
c Ger Lic Class`s" -
.(/ SWIMMING POOL DAT !!! }
CL
Co recto Date SPA FIN 0 n
- scL Fr U
` a exempt under Sec • w SIZE - -
B 8P C for this reason a ELECTRICAL - - + Z - �_ - _ _ }yu�.
Dole ..•' - _ `a aI•J r!' `1 LU
Steel 8 Conduit Bonding T d
Signolu ie Conduits Conductors Equipment _ K s{ Pr a te/@/p 0
SINGLE FAMILY ..
_ -
HOME OWNER-BUILDER DECLARATION PLUMBING • • ,-lL • •iy&_A,:]�9�
I hereby affirm that I am exempt from the Contractor s License _ _ _ - •� ' %i
Law for the following reason (Section 7031 5 Business and ' P Trap yt l r 7 I 4. Q &21 -86
Professions Code) '• + < Gas System
I as owner of the property will do the plumbing and Anti-Syphon '�, 5 2 9 6A
electrical work I or my employees with wages as their _ _ 4, _ d# • • • •_
sole compensation,or a licensed contractor willydo all MECHANICAL t
other work and The structure is not intended or offered - �' j I • 2 9 6 5 0
for sale (Section 7044 B8P Code) Swimming Pool Heater • 1
CONSTRUCTION LENDING AGENCY - .. • • 2 CI S.S 0 ,'
f hereby affirm that there is a construction lending agency for J a _
the performance of the work f r which this permit is issued APPLIC T NO _ •fit Q $2•� -8 6
`(Sac 30'77 Gv C - ,, + r _ ,• ,
6 O � v
Lender s Nam -
ADDR
Lenders Address
P C Fee$ Permit Fee
I certify shat I have read this application and stale that theiD :S +1� Y5 1• 1 �j•�-i ;q, i +
above information is correct I agree to comply with all County - - - rj -t i t - - _
ordinances and Slate laws relating to budding electrical Issuance Fee �U i ' s -r„ i
mechanical and plumbing construction and hereby authorize Investigation Fee -
repres Ives f this County to enter upon the above Total Fee !// + �+J .y• t\
meYn.e,,, ro ty for inspection purposes a of AppLca o Agem -SEE REVERSE FOR EXPLANATORY LANGUAGE