HomeMy Public PortalAbout9444 BROADWAY_Swimming Pool__ �. WORKERS'COMPENSATION DECLARATION
l hereby affirm that !-have a ceLtificate of
ent to
n�,i sar%rfi{ed copy hereof(Sec 3800 Lob.nsCa'ion Insurancelf ^75A208 `�p�'`ICATI�� FOR CORA03GA9ATI0�1 SIhIIAARAIIbG POOL O'�RRAIT
.oXXS5 Z ('��, }CE-875(11/81)
alicy No Compan ///"���"���"���� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. - -
FOR.APPLICANT TO FILL IN BUILDING y
Certified copy is filed with the county building inspec-• ADDRESS C!
tion department BUILDING
• ADDRESS / G LOCALITY
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY ZIP _ CROSS ST.
COMPENSATION INSURANCESIZE OF ASSESSOR
1 TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed If the permit is for one /� TEL. v USE ZONE MAP
hundred dollars ($I00)or less.) j OWNER (/'�CQ�^% NOizp _ NO.
certify that in the performance of the work for which this -�
SPECIAL
permit is issued, I shall not employ any person in any manner j ADDRESS NDITIONS
so as to become subject to the Workers"Compensation Laws. DISTRICT TATISTICAL CLASS TYPE PROCESSED By
CITY ZIP CONST.
Date Applicant ARCHITECT�1/J TEL Q CLASS NO. x
NOTICE TO APPLICANT: If, after making this Certificate of ENGINES NO.&_;VV 01Gj '.�
Exemption, you should.become subject to the Workers' A?7f:3 - VALUATION •v
Compensation provisions of the Labor Code, you.must forth- j ADDRESS
with comply with such provisions or this permit shall be TEL JJ VALIDATION I�-. j
deemed revoked. CONTRACTO - J�wZ .NOaP�,�II 39�-�j S Aa 40
LICENSED CONTRACTORS DECLARATION LIC
t ADDRESS s,$� N0.3,7"
I hereby affirm that I am licensed under provisions of Chapter 9 LIC $
(commencing with Section 7000) of Division 3 of the Business -
and Professions Code,and my license is in full force and effect. CI CLASS
22 DESCRIPTION OF WORK FINAL / D O
- License Number A__6 Lit. Class � Z_J ( SWIMMING POOL t� 2/1' 1 —� 0 ! �
�y LJ DATE `
Contract Date SPA 9 r �" FINAL `/ 0
' SOEFi.�v,..y BY r-i-ate �s�s.r W
am exempt under Sec '' VV VV p,
B.&P.C. for this reason !/ N
ELECTRICAL -�QSB�a :`S O a G-A Z
Date:
Signature Steel &Conduit Bonding - �- csi
SINGLE FAMILY Conduits, Conductors, Equipment f I
• - HOME-OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License D Z a 27 676
Law for the following reason (Section 7031.5, Business and p-Trap
Professions Code): Gas System - o.a 2 7 6 7 E
1, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. 1,or my employees with wages as their 0-9 O 7-8 3
sole compensation,or o licensed contractor will do all MECHANICAL _
other work and the structure is at intended or offered
for sole (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. _ D
(Sec. 3097, Civ. G}
Lender's Name ADDRESS - -
Lender's Address P.C. y 2-,6Fee$ .�1-- Permit Fee L�(V
I certify that I have read this application and state that the '
above information is correct. I agree to comply with all County C'�
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical end plumbing construction,and hereby authorize Investigation Fee r ^ 1�
representatives of this County to enter upon the above- Total Fee 45� /
mentioned property for ' spection purposes.
Signature of scant or Agent Date i SEE REVERSE FOR EXPLANATORY LANGUAGE