HomeMy Public PortalAbout6304 SALTER AVE_Swimming Pool__ e WORKERS'COMPENSATION DECLARATION.
I~hereby aff'irtry tlf�t I have a certificate of consent to self
insure, or a cert'ific{pte of Workers'Compensation Insurance, APPLICATION FOR COMBINATION ,SWIMMING POOL PERMIT
or a certified copy he edf(Sec. 3800 Lob.C.) 76A20B _
..— CE-875(11/81)•
Po c� �ompanyAA a�-��' COUNTY OF LOS ANGELES j BUILDING AND SAFETY
Certified copy I- hereby furnished.
I,7 FOR APPLICANT TO FILL IN BUILDING
yp Certified copy is filed with the county building inspec- ADDRESS a3
tion department. BUILDING
`y ADDRESS ,- 1 . LOCALI)tl Y77--4
Date Ia Applicant „
r— NEAREST t
CERTIFICATE OF EXEMPTION FROM WOR CITY' ZIP. CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one TEL U E ZQ NE MAP n�@ 2
hundred dollars($100)or less.) OWNS 1 NO. ' Q 066
I certify that in the performance of the work for which this - .r (� SPECIAL
permit is issued, I shall not employ an person in an manner ADDRESS - �v CONDITIONS -
P P Y YP Y
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY IP CONST,
Date Applicant ARCHITE R TEL �j CLASS O. �//
~ NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER. N p� `�t� �U
Exemption, you should become subject to the Workers' VALUAT N
'Compensation provisions of the Labof Code, you-must forth- A6DRES (�
with comply with such provisions or this permit shall be , �C�/` VALIDATION
deemed revoked. CONTRAC Ebb
LICENSED CONTRACTORS DECLARATIONLIC. ,`.'
ADDRESS lJ�
I hereby affirm that I am licensed under provisions of Chapter 9 $
(commencing with Section 7000 of Division 3 of the Business LIC' 22,,
( g - ) CITY CLASS )
and Professions Code,and
annd my license is in full force and effect. , DESCRIPTION OF WORK FINAL!� ,��rl
License Number •,�614 Lic. Class SWIMMING OON,. 7 OAT 7,0 �! , al 71'.9A
��•OJ In
SPA y �I xl, # o o e o 2•� 0
Contra?+a � Date I
❑ SQ.E FT..
I am exempt under Sec. SIZ - I 'o o7 3,6.4 IL
H
B.&P.C. for this reason ELECTRICAL o 0 0 7 a 6 4 50 z
Date: '
Signature Steel &Conduit Bonding .03,20-85
g Conduits, Conductors, Equipment
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-TraprrTL
Professions Code): Gas System
,.❑ I, as owner of the-property, will do the plumbing and Anti-Syphon Al 7 2 0 A
electrical.work.1,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL I a•2 5 IR O O
other work and the structure is not intended or offgred'.:
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY o -258,005
1 hereby affirm that there is a construction lending agency for TE
APPLICANT Y2�_/n 0 3,20-85
the performance of the work for which this permit is issued (PRINT) NO./l(�CJjf
(Sec. is N Civ. C.).
Lender's Name ADDRE
Lender's Address
+ '
I certify that I'have read this application and state that the P.C.Fee$ Permit Fee •
abode information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical and plumbing construction,and hereby authorize' Inyestigation Fee 6
representatives of this County to enter upon the above-' Total Fee 6 }.
mentied or inspection purposes.
SignattYre of Applicant A ent Date SEE REVERSE FOR EXPLANATORY LANGUAGE