HomeMy Public PortalAbout6157 RENO AVE_Swimming Pool__ :•� WORKERS'COMPENSATION DECLARAT,IbN
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here y affirm that I have r certificate of consent to Self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers'Compensation Insurance,
�3r a ctt3r t cop hereof(Sec. 3800, Lab. C.)
16A208
1i "FE-875(11/81)
�oli�No. �4� Company Tt+01.._��� COUNTY OF LOS ANGELES BUILDING AND SAFETY
+ kiCertified copy is hereby furnished.
t� FOR APPLICANT TO FILL IN BUILDING.
Certified copy is filed with th�untybuildling spec- ADDRESS
ito dep rime t. ! BUILDING /_ C ��3Q LOCALITY s
ADDRESS lD J
Date Applicant �7 pp
ERTIFICATE OF EXEMPTION FROM WORKERS'f, 1 CITY L I_ ZIP —{ I�7�T d CROSS ST.
COMPENSATION INSURANCE i `••� S E OF ASSESSOR
�� I TRA L T LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed If the k one ' � _\ TEL. USE ZONE MAP `
hundred dollars(5100)or less.) ` ! OW R �U N{,YGJ NO.Z� N0.
I certify that in the performance of the work for which this I SPECIAL 10,
permit is issued, I shall not employ any person in any manner ADDRESS • CONDITIONS
so as to become subject to the Workers'Compensation Laws. "�^ p DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP O CLASS NO. CONST.
Date Applicant ' ARCHITECT OR TEL.
NOTICE TO APPLICANT: if, after making this Certificate of ENGINEER NO. {
Exemption,• you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you.must forth- ADDRESS S f C� VALIDATION
whit comply with such provisions or this permit shall be CONTRACTOR (3-(� O80ks NO. Zgc���-Z VO 5
deemed revoked.
LICENSED CONTRACTORS DECLARATION LArS'r' LIC' `Or�
ADDRESS S$OG 1 v`�4g NO.
I hereby affirm that I am licensed under provisions of Chapter 9 LIC 5
(commencing with Section 7000)of Division 3 of the Business CIT, 451,� CLASS d
and Professions Code,and my license is in full force and effect. i DESCRIPTION OF WORK y� FINAL O
License Number�g�tdZ Ltc. Classy— � 14 SWIMMING POOL S'�� LL7 DATE
l
Z.
Contractor Date S t SPA /
❑ IV V SQ. FT.
I am exempt under Sec. SIZE �O d
B.&P.C. for this reason ELECTRICAL Z
Date: !
Signature Ij Steel &Conduit Bonding �ti'93 2'A
9 l Conduits, Conductors, Equipment
SINGLE FAMILY `.
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm t(tat I am exempt from the Contractor's License 2 0 73 6 4
Law for the following reason (Section 7031.5, Business and P-Tra
Professions Code): Gas System 0 a ° c>
I, as owner of the property, will do the plumbing and ( Anti-Syphon / rp L,
electrical work. I,or my employees with wages as their ` C C"-
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered `
for sale (Section 7044 B&P Code). iI Swimming Pool Heater Q I z
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TEL. 2 ~ 0 0
the performance of the work for which this permit is issued (PRINT) NO. , o n a 1 ,
(Sec. 3097, Civ. C.). � .
2 CC _.
Lender's Name r ►A ADDRESS C 4
Lender's Addressj
• P.C.Fee$ Permit Fee
'.2,
certify that I have read this application and state that the i
above information is correct. I agree to comply with all County Issuance Fee cD
ordinances and State laws relating to building, electrical, I 1
me anical and plumbing construction,and hereby authorize Investigation Fee
re sentatives of this County to enter upon the above- Total Fee t4
VMnedrproperty for inspection purpose .atue of Applicant or Agent D to SEE REVERSE FOR EXPLANATORY LANGUAGE