HomeMy Public PortalAbout9450 BROADWAY_Swimming Pool__ WORKERS'COMPENSATION DECLARATION /'� p
I hereby a certificate
that haver certificate of consent to self APPLICATION,FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers' Compensation Insurance, /9r L PY L '
or o certified copy thereof (Sec. 3800, Lab. C.) 76A20B -
CE-875(11/81)
Policy No: Company COUNTY OF LOS ANGELES ' ✓C_ /BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING tl�0 ( rna
Certified copy is filed with the county building inspec- ADDRESS
tion department. BUILDING
ADDRESS 1 v LOCALITY
Dote Applicant -
CITY '•1 't/ ZIP L' NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS Si.
COMPENSATION INSURANCE - SIZE OF ASSESSOR '
:
(This section need not be completed if the permTRACT LOT LOT NOMAP BOOK PAGE PARCEL
it is for one TEL `, USE ZONE
hundred dollars($100)or less.) OWNER v�� NO. ��-1' ` NO.MAP
I certify that in the performance of the work for which this w� SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS ` J a 1•�i a ] CONDITIONS
so as to become subject to the Workers"Compensation Laws.- /
DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ! ' ZIP CONST.
Date T OR Applicant ARCHITECT fj TEL. !^� CLASS NO. /spy,
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER •S.,'.)1 NO
Exemption,
Exemption, you should become subject to the Workers'
ADDRESS)
�y QY •/&,( (v VALUATION -
S� J ` �1. r
Compensation provisions of the Labor Code, you,must forth- r i VALIDATION
with comply with such provisions or this permit shall be TEL. S -
deemed revoked. CONTRACTORn n .NO.
LICENSED CONTRACTORS DECLARATION gpDRE55 K/j� NO. t
I hereby affirm that I am licensed under provisions of Chapter 9 If
(commencing with Section 7000) of Division 3 of the Business CITY --- - - CLASS }
and Professions Code, and my license is in full force and effect. 6.
DESCRIPTION OF WORK- r•�{ FINAL O
License Number Lic. Class SWIMMING POOL I it IAV/II DATE y�r V
® D K
Contractor Date SPA FINAL /'^
SQ. FT. �2/, By Cc r Fw- tt1
❑ Iam exempt under Sec. SIZE 7 V,/1/ / d
N
B.BP.C. for this reason ELECTRICAL- C ,- 71 pA ?
Date:
Steel 8 Conduit Bonding a
Signature Conduits, Conductors, Equipment �/ r 3O;
SINGLE FAMILY 2
HOME OWNER-BUILDER DECLARATION PLUMBING D .. C� Q
1 hereby offirm.thot I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and P-Trap �•G J_
Professions Code): 817
Gas System _
F'JI I, as owner of the property, will do the plumbing and Anti-Syphon -
LLL4YYJJJ electrical work. I,or my employees with wages as their '? ) q3 p
sole compensation,or a licensed contractor will do all MECHANICAL +, ° o a �
other work and the structure is not intended or offered
-for sale (Section 7044 B&P Code). Swimming Pool Heater )_ o 0'6 8. 04
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there is a construction lending agency for bo e'(0
APPLICANT TEL
the performance of the work for which this permit is issued PRINT .� `
(Sec 3097, Civ. C.). ( )-
� ^) � /` � � : .I 1,129-83
Lender's Name ADDRESS C_ 7 , {"o'V r
Lender's Address % = -
P.C. Fee 0qPermit Fee I
I certify that I have read this application and state that the .- • J.
above information is correct. I agree to comply with all County t`5O
ordinances and State lows relating to building, electrical, Issuance Fee t -j p
mechanical and plumbing construction, and hereby authorize Investigation Fee
repree motives of this County to enter upon the. above-this County to enter upon the. above- Total Fee 2. O Co �O
me t ,ed property for inspect; purpo s. - - CN J
CN
ignature Applicant or Agen - of - SEE REVERSE FOR EXPLANATORYLANGUAGE
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