HomeMy Public PortalAbout9241 BLACKLEY ST_Swimming Pool__ • •Y%DRKV ' COMPENSATION DECLARATION
I'nereby affir"'m that I hove a certificate of consent to self
insure, or a certorcate oorWorkers' Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or o ce t i d copy thereof (Sec 3800, Lab C ) 76A20B
�A� CE876(3/84)
Poli TPoCompanyi COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspec- ADDRESS ,
tion department BUILDING
ADDRESSaAa LOCALITY
Date��GtL_Appl icon
CITY ZIP CROSS
NEAREST
T
CERTIFICATE OF EXEMPTIO OM WORKERS'
COMPENSATION INSURANCE SME OF ASSESSOR
TRACT LOT LOT NO MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one TEL - USE ZONE MAP
hundred dollars ($100)or less ) OWNER N 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 CONDITIONS
SO as to become subject to the Workers'Compensation Laws DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP _` CONST
Dote Applicant ARCHITECT OR TEL U CLASS NO t�I
NOTICE TO APPLICANT' If, after making this Certificate of
ENGINEER NO
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS VALIDATION}
with comply with such provisions or this permit shall be TEL
$
deemed revoked CONTRACTO NO
LICENSED CONTRACTORS DECLARATIONLIC
ADDRESS NO (bZ
I her affirm that I am licensed under provisions of Chapter 9 LIC $
(commencing with`Section 7000) of Division 3 of the Business CITY CLASS
c
and Professions Code and my license is in full force and effect DESCRIPTION OF WORK r-��
( �A�, � FINAL llee 1
License Number IV Lic Clas�— SWIMMING POOL V!t4 +
DATE /
//;; SPA L ® FINA ,`t/ _ ;949,8A Q
Contractor/A`f W'�Date4� ^/
El
SO FT /�p��� R y`1 V
I am exempt under Sec
SIZE vxil #tto a o e '21 cr.
B &P C for this reason ELECTRICAL - 3 01-53 O
Date Steel &Conduit Bonding o+o J 01.5 3 a
Signature Conduits, Conductors, Equipment �S
SINGLE FAMILY .a Z
05 '2-88
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License j + '
Low for the following reason (Section 7031 5, Business and P-Trop ® t r{
Professions Code) ' I Gas System
1, as owner of the property, will do the plumbing and Anti-Syphon
electrical work I, or my employees with wages as their t' -2,9 4 9, 9 A
sole compensation,or a licensed contractor will do all MECHANICAL # o 0 o 0,0 3
other work and the structure is not intended or offered r
for sale (Section 7044 B&P Code) Swimming Pool Heater L 14
CONSTRUCTION LENDING AGENCY - � - o e
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)_ , O
(Sec 3097, Civ C )
Lender's Name V LV.rII�V/WUADDRESS - = 0 S 12 i 8 8
Lender's Address
PC Fee$ V/AJ I V,3 Permit Fee --
I certify that I have read this application and state that the
above information is correct I agree to comply with all County + S O -4,ordinances and State laws relating to building, electrical, Issuance Fee
mechanical and plumbing construction, and hereby authorize Investigation Fee / t
representatives of this County to enter upon the above- Total Fee 1
m ntioned pro er for inspection purposes
,gnature App(cant or Agent Date- SEE REVERSE FOR EXPLANATORY LANGUAGE