HomeMy Public PortalAbout9422 BLACKLEY ST_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I havecertificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) 76A20B
CE876(3'84)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished.
BUILDING
Certified
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS
tion deportment. BUILDING
ADDRESS LOCALITY
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY ZIP CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO, MAP BOOK PAGE PARCEL
(This sec ' n need not be completed if the permit is for one TEL. USE ZONE ESPECIAL
P
hundr dollars ($100)or less.) OWNER NO. .
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner ADDRESS NDITIONS
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.y_
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
with comply with such provisions or this permit shall be TEL. $ VALIDATION
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC.
hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
$
LIC.
(commencing with Section 7000) of Division 3 of the Business CITY CLASS
and Professions Code, and my license is in full force and effect. }
DESCRIPTION OF WORK ❑
License Number Lic. Class FINAL ► 0-
SWIMMING POOL DATE 0
SPA ❑ W
Contractor Date FINAL
SO. FT s t Q
❑ BY
1 am exempt under Sec. SIZE ly
}
B.BP.C. for this reason ELECTRICAL
b
Date: ❑
Steel 8 Conduit Bonding _ 0
Signature Conduits, Conductors, Equipment
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATIONPLUMBING W
I hereby affirm that I am exempt from the Contractor's License , ~
Law for the following reason (Section 7031.5, Business and P_Trap
Professions Code): Gas System a e •
❑ 1, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I, or my employees with wages as their , t t�
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered
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) - NO.
(Sec. 3097, Civ. C.). ,
Lender's Name ADDRESS
Lender's Address
P.C. Fee$ Permit Fee
I certify that I have read this application and state that the i
above information is correct. I agree to comply with all County 1
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical and plurnbing construction, and hereby authorize Investigation Fee
representatives of,/this County to enter upon the above- Total Fee
mentioned prop91ty fdr inspection purposes.
Signatur�'of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE