HomeMy Public PortalAbout5717 PRIMROSE AVE_Swimming Pool_1/4/1996_ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers-Compensation Insurance, APPLICATION FOR COBINATION SWIMMING POOL PERMIT
or a certified cony tlst:revf SSec. 3800, Lob. C.) 7sn2oB
-, � /� C- A CE876(3/84)
Policy Company 2L-A �u r n COUNTY OF LOS ANGELES BUILDING AND SAFETY
E'Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING /
Certified copy is filed with the county building inspec- ADDRESS
tion department. ^ BUILDING___7 7 1 LOCALITY
_ J ADDRESS .� / /
Date Applica ' NEAREST
CERTIFICATE OF EXEMPTI N FROM WORKERS' CITY `�i/j/J�I�L. (_� ZIP 7UC/ CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR py
TRACT LOT LOT NO. MAP BOOK �p / PAGE Q,// PARCEL
(This section need not be completed IF the permit is for one TEL. USE ZONE MAP
hundred dollars($100)or less.) OWNER / YG/ NO. NO.
I certify that in the performance of the work for which thisG t^ SPECIAL
54
permit is issued, I shall not employ any person in any manner ADDRESS 4t CONDITIONS C�
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS I TYPE PROCESSED BY
CITY ZIP CLASS NO. CONST.
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. nv
Exemption, you should become subject to the Workers' ADDRESS VALUATION
Compensation provisions of the Labor Code, you must forth- _ ET(� VALIDATION
with comply with such provisions or this permit shall be /�d a > /�/ TEL. /7Q� $ /5f i
deemed revoked. CONTRACTOR C `!F> 0/_5 NO.6�JJ �
LICENSED CONTRACTORS DECLARATION ADDRES J� L LIC_ C '
I hereby affirm that I am licensed under provisions of Chapter 9 fLIC. _
(commencing with Section 7000) of Division 3 of the Business
and Professions Code,and my license is in full force and effect. CITY, V CLASS `]
_ DESCRIPTION OF WORK
���� ��� FINAL
License Number_ Lic. Class SWIMMING POOL DATE
/ SPA
Conlractorc�fL��a�`�ate 50. FT. { FINAL a
I am exempt under Sec. SIZE JG� BY, CC..
B.BP.C. for this reason ELECTRICAL
C
Date:
Steel 8 Conduit Bonding (�
Signature Conduits, Conductors, Equipment
SINGLE FAMILY D
HOME OWNER-BUILDER DECLARATION PLUMBINGZ
-, Z
I hereby affirm that I am exempt from the Contractor's License , 23
Law for the following reason (Section 7031.5, Business and
Professions Code): Gas System AG *GT■
Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon 3303 194.58
electrical work. I,or my employees with wages as their .,
sole compensation,or a licensed contractor will do all MECHANICAL 'J
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater L_yJ ACCT.®r
CONSTRUCTION LENDING AGENCY 330 t+ 685-86
1 hereby affirm that there is a construction lending agency for APPLICANT -.— ITEMS
the performance of the work for which this permit is issued (PRINT)JON/ O.Lf-/->��
(Sec. 3097, civ. C.). _ TOTAL 8$0. ,44
Lender's Name //'7; /�urr u880.44
L t
ADDRE$ c � /� �+f1C.Cn p6n■77
Lender's Address �(�j / �+ OOU �y
P.C. Fee$ d/O Permit Fee � ._b `' .00
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County a 3
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical and plumbing construction,and hereby authorize Investigation Fee ¢ r 0000'0001 1/ 4/96
representatives of this County to enter upon the above- Total Fee /1 `> , 61 4091 1 AM10:07
mentioned proper for inspection purposes.
�gnature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE