HomeMy Public PortalAbout4933 RIO HONDO AVE_Swimming Pool__ WORKEg-S'CQMPENSATION DECLARATION
Mlere5y Pffirs%�`that I oiave a certilicate of consent to self Iu'
insure, or a certificate of Workers'Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or a ce 'f d c�;ther o 800, Lab. C.) CE876
y \JL/ p y C��� CEB78(3/B4) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Po is No. om an
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING/ 1 /7� (� I o H
ertified copy is filed with the county building inspec- ADDRESS 1 '7 j�
tiop dep rtme` BUILDING
Dat ' t v Applicant ADDRESS �3 R �"�(�N� LOCALITY TEI-419LE C
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKE ' CITY `-e L ZIP CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT) _ �s LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one AA ll r ^'�-� Q TEL. ^� USE ZONE MAP
hundred dollars($100)or less.) OWNER Iv V 1 1 c— - NO.G- NO.
I certify that in the performance of the work for which this /�� L SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS-T —__52> `Q C)�-0 CONDITIONS
so as to become subject to the Workers'Compensation Laws. CITY 1 T��� (� f Zlp DISTRICT STATISTICAL CLASS OPE VPROSSED BY
Date Applicant ARCHITECT OR TELA CLASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER (( �u f�5 NO t ���
Exemption, you should become subject to the Workers gDDRESS�I r-. v^ VALUATION
Compensation provisions of the Labor Code, you.must forth- F- � G U
with comply with such provisions or this permit shall be /,�TEL. VALIDATION
deemed revoked. CONTRACTOR ��,3-] �
`S� C�►�JNCO.
LICENSED CONTRACTORS DECLARATION ADDRESS (CP �}-
I hereby affirm that I am licensed under provisions of Chapter 9 LIC. $
(commencing with Section 7000) of Division 3 of the Business CITY �1(( CLASS CSS
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
GG2to I cJj FINAL
License Number c\Lic. Class SWIMMING POOL � DATE ' d
Contractor `-'Date SPA FINAL /�� 0
❑ SQ. FT.f i _ BY / V V
I am exempt under Sec. SIZE `'fes a:
B.&P.C. for this reason ELECTRICAL
Date: W
Signature Steel &Conduit Bonding In
Conduits, Conductors, Equipment Z
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING ,
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and P-Trap ;291 2 6 A
Professions Code): Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon # a a 0-0,0 3
electrical work. I,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL ( ° a 3 4 2 5
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater o a 1 3 4 2 5 6
CONSTRUCTION LENDING AGENCY O 3.084-88
(ICAN; � TELq G
the performance of the work for which this permit is issued PRINT NO-6�-�0 ,
(Sec. 3097, Civ. )
Lender's Name N_el ADDRESS4C4CPC IN-20 gv& ' 0
LeV,er's Address 3
P.C.Fee$ Permit Fee �j
1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County ! lS
ordinances and State laws relating to building, electrical, Issuance Fee / CJ
me@,hanical and plumbing construction,and hereby authorize Investigation Fee
repr ives of this County to enter upon the above- Total Fee
me tioned op for inspection purposes.
�s �s C'S
Sign lure of Applic or Abent Date SEE REVERSE FOR EXPLANATORY LANGUAGE