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Home My Public Portal About5226 WILLMONTE AVE_Swimming Pool__ i Yt�QIRKERS'COMPENSATION DECLARATION I'herd5by affirm that I have a certificate of consent to self insure, or a certificate ofYWorkersloCompensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT ,-orr a certified copy thereof(Sec. 3800, Lab. C.) 76A20B WIUSP CE876(3/84) Policy No. Compony fi Ma _� COUNTY OF LOS ANGELES BUILDING AND SAFETY F1 Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN Certified copy is filed with the county building inspec- ADDRESS Z� � • tion department. BUILDING e ADDRESS LOCALITY G Dat Applicant T /may �7 �7 NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CITY / X74FZ�C� ZIP 1/6 U 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. SE ZONE MAP hundred dollars($100)or less.) OWNER f C-V NO. — (� NO. I certify that in the performance of the work for which this 11 SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS CONDITIONS so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPEPROCESSED BY CLASS NO.CITY ZIP �� FNSW Date Applicant ARCHITECT OR TEL. t NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. Exemption, you should become subject to the Workers' VAI ATION Compensation provisions of the Labor Code, you must forth- ADDRESS eYJ VALIDATION with comply with such provisions or this permit shall be deemed revoked. CONTRACTOR G NO LICENSED CONTRACTORS DECLARATIONIC. ADDRES O. (/,� 1 hereby affirm that I am licensed under provisions of Chapter 9 LIC $ (commencing with Section 7000)of Division 3 of the Business CITY /1/ �� (� CLAS and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK _ / FINAL ► License Nu/m�betr� 'fib Lic. Class�� SWIMMING POOL �� n �� DATE r }? d�U�E��ate � `�a SPA t �/L a Confracfo ��G'f' / FINAL 21 (� SQ. FT. 1 7 I am exempt under Sec. SIZE BY l �:1Y s 4- 0 AT B.&P.C. for this reason ELECTRICAL ^i 7 101.t Date: Signature Steel &Conduit BondingE25 .L ITEMS N 9 Conduits, Conductors, Equipment A t� SINGLE FAMILY I I AL. 101 m _ ::5 HOME OWNER-BUILDER DECLARATION PLUMBING , CHECK lEI�o�J I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and P-Trap CHANGE XJG Professions Code): Gas System " as owner of the property, will do the plumbing and Anti-Syphon electrical work. I,or my employees with wages as their sole compensation,or a licensed contractor will do all MECHANICAL �13h�I— =I*�1 other work and the structure is not intended or offered i for sale (Section 7044 B&P Code). Swimming Pool Heater j ``I�t}►►== CONSTRUCTION LENDING AGENCY ' / ff�� pn� I hereby affirm that there is a construction lending agency for APPLICANT C� � f�`�LC/ EL. ! ITE the performance of the work for which this permit is issued ) J � —o , TOT AL ma JL .76 (Sec. 3097, Civ. C.). ' J :�� .76 Lender's Name ADDRES — Lender's Address /� J CH r `E It P.C.Fee$ v I ti�`� Permit Fee 3 r � I certify that I have read this application and state that the — above information is correct. I agree to comply with all County /0 -150 ordinances and State laws relating to building, electrical, Issuance FeeOCI,C-x•1,,.1 /� ?'� mechanical and plumbing construction,and hereby authorize Investigation Fee representatives of this County to enter upon the above- Total Fee 2)�I! t7 0703 1 I}'M mentionedpro a ty for inspection purposes. � J� nature of pplicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE