HomeMy Public PortalAbout6453 TRELAWNEY AVE_Swimming Pool__ WORKERS COMPENSATION DECLARATION -I I
hereon cer
a cel That I 1,60 a 4erti to consent .elf APPLICATION FOR COMBINATION SWIMMING POOL PERMIT I(fl
uABre r a HF¢otes of Workers ComompeInsurancensahon Inronce
or a certified copy thereof (Sec380 ab C ) 76q M
Policy Nd/ Compan COUNTY OF LOS ANGELES BUILDING AND SAFETY '
Cerffied copy Is hereby furnished
Cert fled copy Is filed with e c u ry buil c FOR APPLICANT TO FILL IN BUILDADDRESS
3
I..
dopa merit BUILDING �/
I. ADDRESS / , LOCALITY
Da A bcant NEAREST
CERT KATE OF EXEMPTIO ROM WORKERS' CITY ZIP CROSS ST 1�_
COMPENSATIOASSESSOR
N I RANCE TRACT LOT IZE Of LOT NO MAP BOOK PAGE PARCEL
(This section need trot be complot If the permit Is for one TEL USE£ E MAP
hundred dollars($IGO)or less ) OWNER — NO (e* 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 I CONDITIONS
so as to become subject to the Workers Compensation Laws - DISTRICT STATISTICAL CLASS I
TYPE PRpGESSED BY
CITY ZIP CLASS NO CONST /�//
Date Applicant NG NEE RCHIT e NO �1�7 J c
TEL
NOTICE TO APPLICANT If after making this Certificate of
Exemption you should become subject to the Workers VALUATON
Compensation provisions of the Labor Code you must forth ADDRESS �"��`C%Uc� ��/� VALIDATION
with comply with such provisions or this permit shall be CONTRARO `VTEL y 3 f /Y`/1 J
deemed revoked
LICENSED CONTRACTORS DECLARATION ,y �J UC
I hereby off nm that I am licensed under provisions of Chapter 9 ADDRESS- -'6 LNO s
(commencing with Section 7000) of Division 3 of the Business CI ol�i��� C�55
and Professions Code and my license is in full force and effect DESCRIPTION OF WORK
License Num er Lic Class C53 SWIMMING POOL /ll'p♦ LJJ DATE •�— � ' ► }a
Contracto Date SPA
❑ EFT er �6976A yr
am exempt under Set
0 8P C for this reason ( U
7 3 6 4
ELECTRICAL
Date - lel
Signature Steel 8 Conduit Bonding . -,- 73645
a
9 mens Conduits Conductors Equipment SINGLE FAMILY 9 p 0506-t-87
z
HOME OWNER BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor s License _ 6 9 7�7 A
Low for the following reason (Section 7031 5 Business and p.Trop
Professions Code)
Gas System # .,. is •,. 3
1as owner of the property will do the plumbing and Anti-Syphon
electrical work I or my employees with wages as their i ( s 2 5 a O O
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offeredx
for sole (Section 7044 B&P Code) Swimming Pool Heater 2 5 a O O
CONSTRUCTION LENDING AGENCY 0 5 0 6+8 7
hereby affirm that there is a cc nstruct l on lending agency for APPLICANT TEL
the performance of the work for which this permit is issued (PRINT) NO
(Sec 3097 C,v C )
lender s Name ADDRESS /�
Lender s Address P C Fee f i Permit Fee ,.f 71 J (/
vT
I certify that I have rood this application and store that the _
above information Is correcl I agree to comply with all County /
ordinances and State laws relating to building electrical Issuance Fee r rJ O
mec anical and plumnstruction and hereby authorize Irrvestigaoar Fee ` O
r ert2ff!!
toeupop the aboveTotal Fee UI ct n purpo es
L
g r of App mart or Agent t SEE REVERSE FOR EXPLANATORY LANGUAGE