HomeMy Public PortalAbout9114 BROADWAY_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self p p
insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
:or a certified copy thereof (Sec. 3800, Lab. C.) 76A20B
CE-875(11/811'
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETYCertified copy is hereby furnished 1
FOR APPLICANT TO FILL SIN ADDRESS
O BUILDING
Certified copy is filed with the county building inspec- - - ADDRESS
tiogdepartmenf. BUILDING nn -
ADDRESS 7 17 2 g7�E1�Ck LOCALITY-
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY",( C_ _ ZIP CROSS ST.
COMPENSATION INSURANCE SIZE OF I ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not he completed if the permit is for one //++ TEL 8 USE ZONE MAP
hundred dollars($100)or less.) OWNER l.,f k — NO.
J 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'Compensotio.. �+' DI TRICT STATISTICAL CLASS TYPE PROCES ED BY
,L'f CITY / t...t, ZIP � c�(] CLASS NO CONST,
DateApplimnt C��fs'D � ARCHITECT OR - TEL - - - J
NOTICE TO APPLICANT: If,. after .king this Certificate of, ENGINEER NO. 0
Exemption, you should.,become subject to the Workers' '- - VA UATION
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.
YY
I hereby affirm that I am li<ensed'under provt ADDRESS NCuisions ofChapter 9 $
(commencing with Section 7000) of Division 3 of the BusinessLIC.
- CITYCLASS }
and Professions Code,and my license is in full force and effect. _ IL
DESCRIPTION OF WORK ❑ FINAL /O _/�_�� D v
License Number Lic. Class SWIMMING POOL DATE G
aC
FINAL O
Contractor Date. SOP FT ❑ BY
El I am exempt under Sec. .SIZE
34, N
B.BP.C. for this reason - ELECTRICAL ?
Date:
Signature - Steel 8 Conduit Bonding � -
Conduits, Conductors, Equ
SINGLE FAMILY ipment
'
HOME OWNER-BUILDER DECLARATION PLUMBING D ,
Ihereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 70315, Business and p-Trap I�so/-{f
Professions Code): Gas System L—J p3 7 9.2 A
1-1
I, as owner of the ,propertywill do the plumbing and Anti-Syphon ,
electrical.work..1,or my employees with wages as their _ jrt o�e a to . .
sole compensation,or a licensed contractor will do oll MECHANICAL 1 :
other work and the structure is not intended or offered 1 - 1 08.00
for sale (Section 7044 B&P Code). . Swimming Pool Heater EZf a a .) O'� O O U
CONSTRUCTION LENDING AGENCY _ •U,a 2 0 _8,4
I hereby affirm that there is a construction lending agency for APPLICANT //11 TEL
the performance of the work for which this permit is issued (PRINT) ltjr(/ .COOKS NO
). . e '
I .
(Sec. 3097, Civ. C D '
Lender's Name ADDRESS )1"k- 6-1 Gy_0 L( I— (.
Lender's Address- _
P.C. Fee$ Permit Fee 5y '
I certify that I have read this application and state that`the '
above information is correct. I agree to comply with all County `
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical and pfumbing construction, and hereby authorize ln.esrgotion Fee /7 ,
representatives of this County to enter upon the above- I Total Fee
mentioned property for inspection purposes. '
i
51lwe of Applicant or Agent Applicant or Agent Dote SEE REVERSE FOR EXPLANATORY LANGUAGE