HomeMy Public PortalAbout9914 BROADWAY_Swimming Pool__ WORKERS'COMPENSATION DECiARAT10i'I �f)
I hereby affirm that I hove a certificate of consent to self
insure, or,a certificate of Workers' Compensation Insurance; APPLICATION FOR COMBINATION SWIMMING POOL PERMIT � • " "
or a certified copy thereof (Sec. 3800, Lab. C.) 76A20B $
L _ CEB76(3/B4) l _ __ _
Policy Nc iu�b� Company -`tI T't's COUNTY OF LOS ANGELES .,BUILDING AND'SAFETY
Certified copy is hereby furnished. fd— -
FOR APPLICANT TO FILL IN - BULD
ING Q(�
Certified copy is filed with the county building inspec- - ADDRESS 1 1
tion pepal tment. /q- BUILDING Q[
Date 13 Applimnr�,�Lk1� ADDRESS- I/ LOCALITY
`e NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY .ZIP CROSS ST.
COMPENSATION INSURANCE SIZE F ASSESSOR
TRACT LOT LOT NO. MAP BOOK QS U7j PAGE b PARCEL
(This section need not be completed it the permit is For oneQ�I4n TEL. USE ZONE MAP -
hundred dollars ($100)or less:) OWNER `-' .�/s 1 NO. NO.
11 certify that in the performance of the for.which this SPECIAL p '
permit is issued, I shall not employ person in any manner ADDRESS CONDITIONS .A"O
so as to become subje I to th rkers'Compensation Lows. .DISTRICT STATISTICAL CLASS - TYPE PROCESSED BY
CITY ZIP rD A CLASS NO, CONST.
Dole Applicant ARCHITECT OR TEL. OY
NOTICE TO LICANT: If, after making this Certificate of ENGINEER NO.
Exempt , you should become subject Io the Workers VALUATION
Compensation provisions of the Labor Code, you.must forth- ADDRESS
P P TEL.-•7p� -f'l I, VALIDATION
with Comply with such provisions or this permit Shall be CONTRACTOR ,l NIZ 1�0J5 NO.//(JS'I/W S I UDd
ADDRESS
deemed revoked. ¢ _
LICENSED CONTRACTORS DECLARATION �J LIL1'w- LNOIC.. `ZS10_
Y &
I hereby affirm that I am licensed under provisions of Chapter 9 LIC /�' • $ � •
(commencing,with Section 7000) of Division 3 of the Business CITY - CLASS C J3
and Professions Code,and my license is in full force and effect. - s
(�� DESCRIPTION OF WORK L�y�� FINAL
License Number (b'SIU F/ Lic Class "-' S� SWIMMING POOL .!'d'ivCt q /��b 1 r DATE
r� 63Gt� 01(O ., ® r x
Contractor lWL fll� '� Date SPA - FINAL 9G31a SO. FT. ((�� By V
I am exempt under Sec. SIZE w O
B.BP.C. for this reason ELECTRICAL -
Dare: Steel ,Conduit Bonng ® Ul
Signature Conduits, Conductors, Equipment - to
SINGLE FAMILY - - _ z
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License - -
Law for the following reason (Section 7031.5, Business and p-Trap pop.
Professions Code):
Gas System _
I, as owner of the property, will do the plum mg and Anti-Syphon
electrical work. I, or my employees w' ges as their - _ _ +
sole compensation,oro licen ontrac'a, will do all MECHANICAL .-.
other work and the stru is not intended or offered
for sale (Section 7 8P Code). - Swimming Pool Heater riC'-'f.r
CO UCTION LENDING AGENCY `CI? SL_�._•'_
I hereby off that there is a construction lending agency for APPLICANT TEL. (� 7 �! "=- '
the per mance of the work for which this permit is issued (PRINT) ( Ai114 NO.7i�S-2 TOTAL II GI"'
(S 097, Civ. C.). _ _ -�__
Lender's Name ADDRESS �U T UAAIS y�• . . t. ��
L_FIC7-.,it
Lender's Address / i'f.p-- --
P.C. Fee$ ,2eP• b Perrnit Fee -4137 7f CHANGE xLl i
I certify that I have read this application and state Ihar the
above information is correct I agree to comply with all County -
ordinances and State laws relating to building, electrical, Issuance Fee ✓
mechanical and plumbing construction, and her authorize Investigation Fee �Q• d. Ijl ll_!1 I�I�I'Ij �y%l_r`;i
representatives of this County to enter upon the above- Total Fee D _ Art _
mentioned property farrection purposes. tilts ltDi 7 pff i1:LI/
Signature of ppli nl or Agentof ppli nl or Agent unit, SEE REVERSE FOR EXPLANATORY LANGUAGE