HomeMy Public PortalAbout9306 BLACKLEY ST_Swimming Pool__ WORKE�COMPENSATION DECLARATIOtyz'V t .f x y �•��f + = ""e`
F/I ere affir';'tliat I have a certificate of consent to self r �'N SWIMMING POOL
insure, or a Whificate of Worke,s•Compensation Insurance, pAPPLICATION FOR COMBINATIOPERMIT
or a cer fiec; c j,y)ttwr 3£300, Lab C ) 76A2oBT
'•�� CE676(3/84)
P it cyst o` Company F'tl� T-- COUNTY�OF LOS ANGELES BUILDINGANDSAFETY+x
Certified copy furnished
�eUILDING
rtified copy is,filed with the county building,inspec- FOR APPLICANT TO FILL IN ADDRESS
tion,departm,elr BUILDING
ADDRESS LOCALITY f
Date Applicant
i CITY . pau k NEAREST
CEP1,FICATE OF EXEMPTION OM WORKERS'" ZIP'` +� 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 TONE MAP
hundred dollofs($100)or less ) OWNEROtwaANO NO
1 certify that in they performance of the work for which this i . SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS CONDITIONS 7- >
so as to become subject to the Workers'Compensation Laws DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CONST
Date Applicant ARCHITECT OR' TEL CLASS NO %
NOTICE TO APPLICANT If, after making this Ceitificate of ENGINEER NO VO
,
Exemption,.you should become subject to 'the Workers' VALUATION y
Compensation provisions of the Labor Code, you must forth- ADDRESS
n� VALI� T N
with comply with such provisions or this permit shall be CONTRACTOR �� NEOL
� $ w
deemed revoked _
LICENSED CONTRACTORS DECLARATION IC
ADDRESS ��(� O
I hereby affirm that I am licensed under provisions of Chapter 9 LIC $
(commencing with Section 7000) of Division 3 of the Business CITY CLASS
and Professions Code and may license is in full forcc+e'ranndd effect DESCRIPTION OF WORK `d /� �i ,
`✓✓I✓` Lic Class(�2 �w►^' FINAL, 9 8 2 1 A
License Number SWIMMING POOL t �� '
DATE '
J0 0C
Contractore.&LlTE Ff �2 Date SPA
SQ.FT � � BY I ° ,1 01,54
0 1 am exempt under Sec y SIZE
1121:�
B&P C for this reason ELECTRICAL /-l�,�i 'i�, ° -JQ,1,5 44:
Date fQ J- 0 6,08,-88 Lys
Steel & Conduit Bonding CL
SignatureConduits, Conductors, Equipment }
SINGLE FAMILY Z
HOME OWNER-BUILDER DECLARATION PLUMBING ;99822A
I hereby affirm that I am exempt from the Contractor's License
Law for'the.following reason (Section 7031 5, Business and tA
p-Trap t ii ,°,° etre • 3
Professions Code)' Gas System ,"° 3 5 1 7 6
1, as owner of the property, will do the plumbing and Anti-Syphon ,
electrical work 1, or my employees with wages as their ' ° ° 3 517 6
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or,offered 0 6 0 84 8 8
for sale (Section 7044 B&P Code) Swimming Pool Heater y
CONSTRUCTION LENDING AGENCY
I hereby affiim that there is a construction lending agency for
the performance of the work for which this permit is issued APPLpR NTT
TEL
(Sec 3097, Civ C ) ( NO,79G-2 ® _
Lender s Name 1`r �"r 1�1
ADDRESS
Lender's Address
PC Fee$ �V Gv PermitFee
I certify that I have read this application and state that the
above information is correct I agree to comply with all C=ounty x '
Fee
ordinances and State laws relating-to building, electrical, Issuance 0
mechanical and plumbing construction, and hereby authorize Investigation Fee y
representatives of this County to enter upon the above- Total-Fee „
ph�;�Etd �inspection purposesture of Applicant or Agent Date ,SEE REVERSE FOR EXPLANATOKY"LANGUAGE +' "` • d ± r `� ' bZ