HomeMy Public PortalAbout10781 BLACKLEY ST_Swimming Pool__ COMPENSATION DECLARATION
hereby, a certifthat'Iicate
hale r cerlrficate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
ms or a certificate of W rkers' C ensation Insurance,
•'.o a i dopy th eof ( 38 La C ) 76A20B
l/J//� CE;875(11/81)
It �mpony_ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. _
) FOR APPLICANT TO FILL IN BUILDING �^
�Certi ed co is filed with nt 'Itling ec- — ADDRESS i b7 $ I �• ()
ho eparr enr.� BUILDING 72 LOCALITYT� P Q:!':
t ADDRESS / O
Date `` pplicant NEAREST r
CITY ZIP CROSS ST a
CERTIFICATE OF EXEMPTION FROM WORK
COMPENSATION INSURANCE SIZE ASSESSOR
TRACT LOT LOT NO MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one TEL8'1-W614
61 US ZONE MAP ,f
hundred dollars($100)or less.) OWNER NO �7 ' NO
I certify that in the performance of the work for which thisf //., SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS O w` / G� CONDITIONS
so as to become subject to the Workers'Compensation Laws DIST ICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CON
Date Applicant ARCHITEC t I TEL �^/�� _ CLASS NO
NOTICE TO APPLICANT If, after making this Certificate of ENGINEER Mf NO k.117`V
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRES
with comply with such provisions or this permit shall beTEL $ ?5 � % VALIDATIO
deemed ievoked. CONTRACT NO04�'g / 1
LICENSED CONTRACTORS DECLARATION LIC `
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRES $
(commencing with Section 7000) of Division 3 of the Business_ LIC
and Professions Code, and my license is in full force and effect CITY CLASS O
(!\ DESCRIPTION OF WORK FINAL � 1 828-A
License Numbe v Lic Class _ SWIMMING POOL DATE V
1l L �]J SPA - T
Contract r r SQ FT a 9 BY A '•1'o 0 6aO5 5 u
I am exempt under Sec SIZE I �
B &P C. for this reason ELECTRICAL ° ° ° 6 8 (] 5 5;
Date EZ X4'1 1 -85
d
Signature - Steel 8 Conuit Bonding ,
SINGLE FAMILY
Conduits, Conductors, Equipment
_
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License 1 8.2
Law for the following reason (Section 7031 5, Business and P-Trap #'o o•0 0 0
Professions Code) Gas System I °.239.36
ElI, as owner of the property, will do the plumbing and Anti-Syphon =
electrical work. j, or my employees with wages as their ° - 239.36 5
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered _A4 p 4,11 =8 5
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TEL
the performance of the work for which this permit is issued (PRINT) N00V_e_G*�IL ,
(Sec 3097, Civ �C
Lender's Name ■ �' ADDR
Lender's Address 6 Cid (W' c
P C Fee$ (} � Permit Fee � � V, -76
I certify that I have read this application and state that the
above information is correct I agree to comply with all County �y
or es
State ws relating to building, electrical, Issuance Fee V r
mechani al and m in onstruction, and hereby authorize Investigation Fee �y
represen ative "o this C unty- to enter upon the ab ve- Total Fee
mentione I for pection purposes
Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE
,