HomeMy Public PortalAbout10608 DAINES DR_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
'insure a aft-ce, that have a �eitCome of consent to self APPLICATION FOR COMBINATION SWIMMING P®®d PERMIT
insure, or a2ertif icote of+Norkers' Compensation Insurance,
or a certified copy e3800, Lab. C.)_ ` ]68201 certified
copy
thereof l/./sN 76A20B 3/B4) _
P o. ompa y COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
I L BUILDING
Ill��'���ff����--ertified copy is filed with the unty building inspec- FOR APPLICANT TO FILL-IN BUDDING
.tion deportment. _ BUILDING ,. C j t
`` '-+'-LI -,�'1I ADDRESS �t�LJ�� ( K1LOCALITY
Date�App iconsNEAREST
CERTIFICATE OF EXEMPTION FROM WORKE '
CITY I ' ZIP CROSS ST.
COMPENSATION INSURANCE ASSESSOR
TRACT LOT LOT NO. ( / MAP BOOK PAGE PARCEL
(This section need not be completed If the permit is for one TEL.r '� ��. USE ZONE OP
hundred dollars (S100)or less.) - OWNERC7--)" � NO.YY �//�
I certify that,in the performance of the work for which this /� USE
� I SPECIAL
permit is issued, 1 shall not employ any person in any manner ADDRESS - /-T , /" ' CONDITIONS
so as to become subject to the Workers'Compensation Laws. ,�fI f� DISTRICT STATISTICAL CLASS• TYPE PROCESSED BY
CITY 111 /G ZIP
CLASS NO.
Dote Applicant ARCHITECTOR -i fps iEjj....I.-pl' �j`/ [.� X21 i n
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NC.Y yy' O Q /
Exemption, you should become subject to the Workers' }-I j . I u VALUATION ��•' J1
Compensation provisions of the Labor Code, you,must forth- ADDRESS ' 11 .V -
with comply with such provisions or this permit shall be CONTRACTOR .NL (� $ I Z VALIDATION
deemed revoked.
LICENSED CONTRACTORS DECLARATIONAODRES l NO.Zu�4 LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 LIC f
(commencing with Section 7000) of Division 3 of the Business CITY LJI !�rT CLASS CS
and Professions Co a and m tic n e is in full force and effect. DESCRIPTION OF WORK
44�) l/� FINAL � �
Ucense/u ern ' l) Lic. Class �� sWIMMiNG POOIn „/I / DATE `��� D {j ;29525A
Cont rocJor k �'_ P��ote / SPA ../\T/✓ LCL' FINA 'f o e $•�'� }
SQ. FT. /
I am exempt under Sec. SIZE BY ✓ o o .-79.21 c=j O
B.BP.C. for this reason ELECTRICAL L-A CA-' U
0503-88
Dore: a
Si nature Steel & Conduit Bonding ! U
g Conduits, Conductors, Equipment W
SINGLE FAMILY 0-
HOME OWNER-BUILDER DECLARATION PLUMBING 9 5 2 b A Z
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason,(Section 7031.5, Business andp-Tra
r_1I e e.�o e e 3
Professions Code): Gas System .i s
I, as owner of the property, will do the plumbing and Anti-Syphon ( e 2,7 6 7 6
electrical work. I, or my employees with wages as their 6sole compensation,or a licensed contractor will do all MECHANICAL - 0503-8 8
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater 1 Y/1 t \ )„•� t'+> f
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICAMP TEL.
the performance of the work for which this permit is issued (PRINT Ll NO. D
(Sec. 3097, Civ. C.) •A yn ` -yn} �t - -
Lender's Nome , —v ADDRES0t� �'fin.`\2-U 6, • ` ,F CUL &A-
Lender's Address `l r z ,2^
P.C.Fee E / Permit Fee K 0 1 s
I terrify that I have rend this application and state that the 1
above information is correct. I agree to comply with all County O Sv •I t ' ,s L .1
ordinances and State laws relating to building electrical, Issuance Fee
mechanical and plumbing construction, and hereby authorize, Investigation Fee ,] / `7 /
representatives of this County to enter upon the above- Total Fee / 6 / f0 t
mentioned r'pe yor inspection purposes.
Signature o Applicont o. gen Date 'lb�rJy SEE REVERSE FOR EXPLANATORY LANGUAGE