HomeMy Public PortalAbout9720 BROADWAY_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a cer9fic6te n' consent Io self APPLICATION
insure, or a certificate of Workers' Compensation Insurance, APPLICATION F®R COMBINATION SWIRARAING POOL PERMIT
or certified copy thereof (Sec. 3800, Lab, C.) 76A200
(of��jp t5/�Lf��./� cE-875(11/81)
P .c o. omponnished .V,TT COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
TO FILL IN BUILDING
Certified copy is filed with the county building inspe<- FOR APPLICANTADDRESS
tion department. � ( ,, BUILDIN
Date 3APPIicani-J�L-� ADDRESS ��/���� LOCALINEARESTY
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY �6%7_ ZIP CROSS 57.
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.yf_ USE ZONE MAP �J
hundred dollars($I00)or lass.) OWNER O �/� 0 NO /./ Cy 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 b ome subject to the Workers'Compensation Laws. ISTRICT STATISTICAL CLASS TYPE PROCESSED BY
77 ,/ ` CITY ZIP CONST.
Date J� Applicant S( N �s.� ARCHITECTO / TEL. CLASS NO. /
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER L f N ^O [� .ci//
Exemption, you should become subject to the Workers• rr VALUATION
Compensation provisions of the Labor Code,.yow must forth- ADDRESS go
[I�
with.comply with such Provisions or this permit shall be TEL.`, /'. VALIDATION
deemed re evoked. p p CONTRACTOR ,� � NO'f -p f /• �(/h/
LICENSED CONTRACTORS DECLARATIONgDDRES NO.
I hereby affirm that I am licensed under provisions of Chapter . �' LIC Y
(commencing with Section 7000) of Division 3 of the Business CITY CLASSC.. _.f Y
and Professions Code,and my license is'n full force and effect. 0
� DESC IPTION OF WORK �r FINAL O
License Number C Lic. Class-47�3 SWIMMING POOL -5-1—pi,v •�s��f_ y� DATE Z to D V
' //./�- � 7 flj�Cjl1 oe
Contmrtc r�y Date S - 31_ $S FT FINAL /' V
I7 SIZE Q BY
am exempt under Sec.
ty
N
B.BP.C. for this reason ELECTRICAL '�-•23 Y8 A Z
Date:
Steel 8 Conduit Bonding #re'o 0 - 21
Signature t Conduits, Conductors, Equipment
SINGLE FAMILY °•°
HOME OWNER-BUILDER DECLARATION PLUMBING '2 7 9.21
1 hereby affirm that 1 am exempt from the Contractor's License D��t o•o -7 0,'2 1
Low for the following reason (Section 7031.5, Business and P Trap
Professions Code): Gas System 0531 -83
El 1, as owner of the property, will do the plumbing and Anti-Syphon .
Of ✓
electrical work. I, or my employees with wages as their '2339P-
sole
2339A-
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered r ° °.° ° 3
for sale (Section 7044 B&P Code). Swimming Pool Heater IJogl' 2'. 3" ,
3.9 7
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TEL. /�f ° ° j 5 5.9 7 v
the performance of the work for which this permit is issued (PRINT/.< 3 �e y`�
Sec. 3097, Civ. C. . D
Lender's Name ) C !' S 3 1 -83
ADDRESS c! V1
Lender' ess o e '✓q
P.C. Fee S Permit Fee
certif that I ave read this application and state that the Sr o a M1H
above i f ati n is correct. I agree to comply with all County W NPU. ,N
ordin s d State laws relating to building, electrical, Issuance Fee J UJ
me anic I nd plumbing construction, and hereby a thonze Investigation Fee
r resent a of this County to enter upon th obov - Total Fee N J-.1 01
ned a ty for inspection purposes; , �•. CN C',011 �
/ ! 3 CH
Signature of pp icon Date CCCCCC J SEE REVERSE FOR EXPLANATORY LANGUAGE