HomeMy WebLinkAbout1641A 1953A (9)WORKERS' COMPENSATION DECLARATION - -
I ke eby affix thn ka
m _ of `ar=e
1lf` APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers Compensation Insurance,e
u
ora certified copy thereof (Sec 381 lab G.) 76
Azoa -
.� C[878 (3/04) _
Policy No Comppny COUNTY OF LOS ANGELES
® Certifiedcopy is hereby furnished. BUILDING AND SAFETY
Certified copy is filed with the county building inspec-
tion department. _
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for ones?
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this.;
permit is issued, I shall not employ any person in ony manned
so as to become subject to the Workers' Compensation Laws.', f.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'.ii
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business:'!_
and Professions Code, and my liven is in full force and effect.
License Number ,a Lic. Class J
Contractor IVB 6!ul
Date
® I am exempt under Sec.
8 &P C. for this reason
Date:
Signature
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and '
Professions Code): -
1, as owner of the property, will do the plumbing and
electrical work. I, or my employees with wages as their -_
sole compensation, or a licensed contractor will do all
other work and the structure is not intended or offered -
for sale (Section 7044 B&P Code),
CONSTRUCTION LENDING AGENCY
i hereby affirm that there is a construction lending agency for '
the performance of 4workforthis permit is issued
{Sec. 3097, Civ. CLender's Name
Lender's Address—_certify that i have n and state that the t
above information is correct. I agree to comply with all County s;
ordinances and State laws r ting to building, electrical, is
mecha icaI a d plumbi co ruction, and hereby authorize
re re3'olon Co y to enter upon the above
-
m ❑t, red erty f r i - 'tion purposes. j
�FJrp -(z
of Ap t or Ageiv Date
FOR APPLICANT TO FILL IN
BUILDING
-
"INADDRESS
ADDRESS
ADDRESS
LO CALITY ,
CITY a+{
/
NEAREST
/T
P /
CROSS ST,
SIZE OF
TRACT LOT
LOT NO.
ASSESSOR
MAP BOOK - AGE
PARCEL
OWNER s"1 ,L4JJ
Vi3EAf NO, i2 TELLUSE
ZONE
MAP
NO,
ADDRESS P I 4
SPECIAL
/ ? 1;r^'
CONDITIONS
CITY
ZIP
DISTRICT
I v
STATISTICAL CLASS
CLASS NO.
TYPE
CONST.
PROCESSED BY
ARCHITECT OR y��EL.
ENGINEER
ADDRESS
VALUATION -
� - VALIOATIO$'1
$
-
$
1' TEL�--
CONTRACTORNS �!5!> NO
ADDRE 7 NO.41g87
LIC.
�in
�J IV/(l/% CLA55
FINAL Q \ ►
DATE `ij.-Zp-�
tP 1 6 4. 1 A -
DESCRIPTION OF WORK
SWIMMING POOL
r.®a
Z. 21
SPA
FINAL
SO. FT.
SIZE
BY
G �- -
s e 5 L' S
gg
j ELECTRICAL
90 ab
Steel &Conduit Bonding
Conduits, Conductors,
Equipment
S
(�
PLUMBING
-
GasGass
System
--
Anti-Syphon
-
MECHANICAL
,( C E� 3 A
Swimming Pool Heater
- p_
s
APPLICANT
(PRINT)
NO.
ADDRESS
-
P.C. Fee $ Permit Fee \
l/lam.
ant
ss a Fee v
Investigation Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
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