HomeMy Public PortalAbout6005 SULTANA AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION I
hereby a Ver%lim that have Mers'Compensation
atpe of tion Insurance,
to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
,(nsu e,• r a L•ert'iftcatr+df Wor�lers'Com ensation Insurance, I G
r Haertified i�ytheireoff(Sec. 3 , Lab C.) R isnzoB
No�1`) e�mpa CE876(3/84?
I COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING �+
Certified copy is filed with a county build ADDRESS MJ
tion departmen BUILDING i Imo_ �!
ADDRESS ALITY
plicanf CITY j ZIP CROS$ST. ��`'I`Orb18•(
CERTIFICATE OF EXE ON FROM WORKERS' SIZE OF ASSESSOR '
i COMPENSAT N INSURANCE TRACT I LOT LOT NO. MAP BOOK PAGE PARCEL ,
(This section need not be completed if the permit is for one i M • os TEL. ZONE MAP
hundred dollars($100)or less.) OWNER � 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(-30C r r CONDITIONS
so as to become subject to the Workers'Compensation Laws. i /'1 DISTRICT STATISTICAL CLASS TYPE PROCESSED,BY
CITY ZIP O CONST.
.
CLASS NO.
no
Date Applicant ARCHITECTO-rl I TEL. � � f
NOTICE TO APPLICANT: If, after making this Certificate of -ENGINEER! NO.17
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you-must forth- ADDRESS
with comply with such provisions or this permit shall be CONTRACTOR N $"with
deemed revoked.
LICENSED CONTRACTORS DECLARATION LI
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS O NO.
23
(commencing with Section 7000)of Division 3'of the Business LIC' $
and Professions C d and license is in full force and ffect. CITY CLASS
A
Y DESCRIPTION OF WORK( t 7n�7TO i 1
License Number Lic. Class-� SWIMMING POOL �]� P DATE ( , 330 17kr°�
1a� ► �:
Confracto ate � � a SQ FT. � � BYSPA AL Y' et4�I°g O
AL
I am exempt under ec. o i CC (��
B.&P.C. for this reason ELECTRICAL 3's4 �2°f1`;
Date: V� 2 ITEMS •• w.
Signature Steel &Conduit Bondingd.
Conduits, Conductors, Equipment i �; TOTAL' 646..4
SINGLE FAMILY F i s} +f :r , CHECK 646.40'
HOME OWNER-BUILDER DECLARATION PLUMBING �
I hereby affirm that I am exempt from the Contractor's License , , CHANGE100
Law for the following reason (Section 7031.5, Business and CHANGE .
100
Code): P-TraGas System
t
I, as owner of the property, will do the plumbing and Anti-Syphon 0000 001 5/17/90electrical work. I,or my employees with wages as their i
sole compensation,or a licensed contractor will do all MECHANICAL 0741 1 AM10:19
other work and the structure is not intended or offered {
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY ll Jl
I hereby affirm that there is a construction lending agency for APPLICA + TEL �y
the performance of the work for which this permit is issued (PRINT) NO..t ,
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS
Lender's Address
P.C.Fee$, Permit Fee
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County ` j I
ordinances and State laws relating to building, electrical, Issuance Fee i
mechanical and plumbing construction,and hereby authorize Investigation Fee
repr enfofives of this unfy to enter upon the above- ' Total Fee
me 1i ned pr`o`per for in ectil n purposes. — }
ti
ignature of Applicant or Agent Date i EE REVERSE FOR EXPLANATORY LANGUAGE