HomeMy Public PortalAbout5002 PERSIMMON AVE_Swimming Pool__ WORKERS'COMPENSATION DEGLARAIy�N
hereby affirm that I have r certificate of t, sent to self APP ICA�ION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers'Cotfipensat �n Insurance,
Ile cow thereof(Sec. 38 b. C. �6A20B
"Po1ic�N �� �rJtmpan�� ✓_L_ CE-875(11/81) COUNTY OF LOS ANGELES ' BUILDING AND SAFETY
Certified copy is hereby furnished.
BUILDING
FOR APPLICANT TO FILL IN
Certified copy is filed with t e county build ng i pec- ADDRESS Sa d a
tion d artm BUILDING cr"�
tr✓ ADDRESS 04P �/ LOCALITY
Dat ® r/ pelican ®��� NEAREST
CERTI I ATE OF EXEMPTION FROM WORKERS' ZIP CROSS S7.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE I PARCEL
(This section need not be completed if the perms}is for one EL, USE ZONE r1Pp07EC
a
hundred dollars($100)or less.) OWNER ' O. �I certifythat in the performance of the work for which this i IAL
permit is issued, I shall not employ any person in any manner ; ADDRESS 1 � DITIONS
so as to become subject to the Workers'Compensation Laws. 09TRicr STATISTICAL CLASS TYPE PR SSED BY
CITY ZIP CONST. •
Date Applicant I ARCHITECT O � �� TI L• CLASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of
ENGINEER ly d '
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you.must forth- ADDRESSTEL �/°�� VALIDATION
with comply with such provisions or this permit shall be CONTRALTO N :6 $ C.�
deemed revoked.
LICENSED CONTRACTORS DECLARATION LIC•
ADDRES NO.
1 hereby affirm that I am licensed under provisions of Chapter 9 ♦ LIC $
(commencing with Section 7000)of Division 3 of the Business CITY / CLASS
dIL
and Professions Code,any li ense in full force and effect DE RIPTION OF WORK _ O
v FINAL
License N tuber/ Lic. Class I SWIMMING POOL /1j�, r� ��(p DATE "`� ►
c ` Date/--! SPA /""" FINAL
Contra
• i SQ. FT. BY F- •t,�_:�t
v UA
I am exempt under Sec. SIZE ,6 2 IL�I A A.
B.&P.C. for this reason ELECTRICAL
Date:
Signature Steel &Conduit Bonding 2`0 - 6247
SINGLE FAMILY Conduits, Conductors, Equipment /' �r3
HOME OWNER-BUILDER DECLARATION PLUMBING ® ,
0 0624
I hereby affirm that I am exempt from the Contractor's License ( � 2 U _ 3
Law for the following reason (Section 7031.5, Business and p-Trap
Professions Code): Gas System
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 6 2 4 5 A
other work and the structure is not intended or offered
for sale Section 7044 B&P Code). O '- 0 0 0 0 0 3
( ) Swimming Pool Heater
CONSTRUCTION LENDING AGENCY P o 1 1 57 5 O
1 hereby affirm that there is a construction lending agency for APPLICANT TE
the performance of the work for which this permit is issued (PRINT) a NO ,� 3 0,0 1 1 5505
(Sec. 3097, Civ. C.).
Lender's Name ADDRES v e
�� In24-83
Lende s Address �,
P.C.Fee$ q r Permit Fee �J �
I certify t 1 hav this application and state that the
above infor is corr I. I agree to comply with all County 0
ordinances tate la s relating to building, electrical, Issuance Fee G s �
mechanic and p mbi construction,and hereby authorize Investigation Fee
prese olives of County to enter upon t ab - Total Fee /
m ed propert spection purposes.
Signa re of Xpplicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE