HomeMy Public PortalAbout5346 TEMPLE CITY BLVD_Swimming Pool__ WORKERS,COMPENSATION DECLARATION
hereby affirm thatt7of e a certificate ns cement r self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure or o cerhficai of Workers Compensation Insurance
or
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COUNTY OF LOS ANGELESBUILDING AND SAFETY
C rtified copy is hereby furnished
FOR APPLICANT TO FILL IN BUILDING 3
tion deep copy n filed with the county building mspec ADDRESS n
tion department DIL
DD 53 _r8 `r LE CA LOCALITY (.
Date Applicant _
CERTIFICATE OF EXEMPTION FROM WORKERS CITY (� ZIP 17 CROSNEARS ST
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO ANAP BOOK( PAGE PARCEL
Vhis suction nwd not be completed FF the pennH Is ler one USE ZONE MA
hundred dollen ($100)or leu ) OWNER (c
1 certify that in the performance of the work for which this -�y� ,� ��, SPECIAL -
permit is issued I shall not employ any person in any manner ADDRESS 53 1 OLA I /7�\ CONDtTIONS
so as to become subject to the Workers Compensohon Lows CCTV �"� ZIP DISTRICT STATISTICAL CLASS CO T PROCESSED BY
Date Applicant ARCHITECT OR TEL 6- CLASS NO
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO
Exemption you should become subject to the Worker VALUATION
Compensation provisions of the Labor Code you must forth ADDRESS '
with comply with such provisions or this permit shall be CONTRACT NO �rj fvV10� VALIDATION
deemed revoked L ✓ COD
LICENSED CONTRACTORS DECLARATION ADORE TVv. k!5 _ r S (o2
I hereby affirm that I am licensed under provisions of Chapter 9 "tJA� /-�C
(commencing with Section 7000)of Division 3 of the busmen CITY UClA55 N� J a>
and Professions Code and my license is in full force and effect DESCRIPr10N OF WORK _
r0,5 o 2 DATE ►
License Number (���1 c Lic Class S.S1L SWIMAUNG POOL S} q n a q�,� Ir-✓��I/ DATE
Contractor 66LI r R` OI LJ Date 1 O SPA' 1 Q(� V' u FINAL }
❑ SD R BY
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am exempt under Sec SIZE �� as `JL
B 8P C for this reason ELECTRICAL 0=
Dare _ O
i
Signature Steel 8 Conduit Bonding U
Conduits, Conductor Equipment d
SINGLE FAMILY N
HOME OWNER BUILDER DECLARATION PLUMBINGZ
I hereby affirm that I am exempt from the Contractor s License ,
Law for the following reason (Section 7031 S Business and p Trap
Profession Code) Gas System
1 as owner of the property will do the plumbing and Anti-Syphon �� 95.95
electrical work I or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL 3
other work and the structure is not intended or offered
44 '
for sale (Section 70BSP Code)_ Swimming Pool Heater TACAICT A
1.f
CONSTRUCTION LENDING AGENCY 3.�7 .�
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issuedTEL 1
(Sec 3097 civ C I (PRIM NO 2 IT1f8
Lender s Name ADDRESSA300 q 17 F TOTAL 3468.95
Lender s AddressC CM rK 3Q.95
Mmit Fee ��sL IIAA��LI�� O�tIITT
I certify that I have read this applicationP C Fee S /on and state that the N.TBVTs� .IW
above mformahon n correct I agree to comply with all County Q
ordinances and State laws relating to building electrical Issuance Fee
mechanical and plumbing construction and hereby authorize Imesugonon Fee n�tsnNns__nrtrryvss a -r pp
representatives of 'hi County to enter upon the above Total Fee 7.3 •� �OOID F-YWl V/1(�Gy
me k red proper f spechon purposes
5139 1 AM11:23
nature of App4icant or Agent Dote SEE REVERSE FOR EXPLANATORY LANGUAGE