HomeMy Public PortalAbout6202 PRIMROSE AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
he4yt affirm that I have a certificate'of consent to self
insure, or,a certificate of Workers'Compensation Insurance, APPL4CAIION .FOR COMBINATION SWIMMING.-POOL PERMIT
or a certified copy thereof(Sec. 3800, Lab.,C.) 78A208
CE876(3/84)
Policy No. Company COUNTY OF LOS ANGELES BUILDING:AND.SAFETY
�. Certified copy is hereby furnished. FOR APPLICANT f'
BUILDING / ;f:
Certified copy is filed with the county building inspec- TO FILL IN - ADDRESS ���
tion department. BUILDING r
ADDRESS Y LOCALITY-
Dale Applicant NEAREST
CERTIFICATE OF EXEMPTION_FROM WORKERS' 10 CITY IP CROSS ST.
COMPENSATION INSURANCE SIZE ASSESSOR
• [TRACT LOT - LOT NO. MAP BOOK. � PAGE 1; PARCEL0�(This section need not be completed If the'permit Is for one TELUSE.ZONE - MAP.-
hundred dollars.(5100)or less.) WNER NO. NO:
I 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 �{r r CONDITIONS
so as to become subject to the Workers'Compensation Laws. ZIP DISTRICT -STATISTICAL CLASS TYPE ST PROCESSED BY
CITY y+ CLASS NOe��e
Date Applicant EARCHITECT NGINEER v Jk TEL.' �� `3/
NOTICE TO APPLICANT: If, after making'this Certificate of a NO�_,,�.I
Exemption, you should become subject. to the Workers' ADDRESS 1 � �V t b�+� VALUATION
Compensation provisions of the Labor Code,.you-must forth- ,■�,// 1� $ q� VALIDATION
with comply with such provisions or this permit shall be CONTRACTOR L` NO. t No
�,
deemed revoked.
LICENSED CONTRACTORS DECLARATION LIC'
ADDRESS t NO.
I hereby affirm that I am licensed under provisions of Chapter 9 LIC S
(commencing with Section 7000)of Division 3 of the Business CII., CLASS
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
FINAL,
License Number L'ic. Class SWIMMING POOL• DATE - ►
Contractor Date SPA FINAL•
SQ.FT. BY d
'I am'exempt under Sec: SIZE _ C
B.BP.C. for this reasonELECTRICAL Cr
Date: C
Steel &Conduit Bonding L
Signature Conduits, Conductors, Equipment
SINGLE.FAMILY U
HOME OWNER-BUILDER'DECLARATION PLUMBING Z
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and P-Trap
Professions Code): Gas System
-1, as owner of tfie property, will do the plumbing and Anti-Syphon CT■s
electrical work. I,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL 140■09
other work and the structure is not intended or offered 3303
for sale (Section 7044 B&P Code). Swimming Pool Heater. ( 3
CONSTRUCTION LENDING AGENCYr ; CT■AA
I hereby affirm that there is a construction lending agency for APPLICANT �+ TEL.
the performance of the work for which this permit is issued (PRIM Kt-A j NO. 3303 .501"?7
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS t3rwz
. ,'c+ 2 ITEMS
ISJ'
Lender's Address
�,. I TOTAL 64 1.,81
� � hr
P!C.Fee$ /��� Permit Fee CHECK 641■31
1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County a7 CHANGE Aordinances and State laws relating to building, electrical,. Issuance Fee
mechanical and plumbing construction,and hereby authorize Investigation Fee
representatives' of this County to enter upon the above- Total Fee
me ioned property for ins p ction purposes. 0000-0001 11/ 9/95
3737 1 AM 9:04
Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE