HomeMy Public PortalAbout9420 DAINES DR_Swimming Pool__ PERS'COMPEN_
her affirm that I havea self
insure, a certificate of Workers ante APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or a cen. ied -copy thereof (Sec. 38w., 76A206
/�Jj� 7 - CE876(3/84)
Policy N�o� Company /' f�L • ��� COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy.s hereby furnished.
�✓ FOR APPLICANT TO FILL IN BUILDING
Certified copy .s filed with the county building inspec- ADDRESS Q
tion department. BUILDING
ADDRESS : LOCALITY
Date 44'C� � Applicant — NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY C �l ZIP CROSS ST. vie
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK AGE PARCEL
(This section need not be completed if the permit is for one TEL. 1JSE ZONE MAP
hundred dollars ($100)or less.) OWNER `- NO. S NO.
I certify that in the performance of the work for which this r— P� SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS r ^- CONDITIONS
sous to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
PP CITY ZIP �� CONST.
Date Applicant ARCHITECT OR TEL. CLASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS �Y
TEL. VALIDATION
with comply with such provisions or this permit shall be CONTRACTOR f F LSC c NO.2 2 � S
deemed revoked.
LICENSED CONTRACTORS DECLARATION �� LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS _. �,� (//l S N0.1 lIJ2. $
(commencing with Section 7000 of Division 3 of the Business UC.
( 9 ) CITY ,� it _ ,'� •� �L CLAS�7
and Professions Code,and my license is in full force and effect. ACCT.j
DESCRIPTION OF WORK � FINAL '*
SWIMMING POOL q DATE ► 313-D77.Ir 7J
License Number Lic. Class Ifi�.I�
� / �Df �-0ate ��� SPA /l LJ FINAL �.
Contractor C7 / BY ACC rT _.,.,.., ._ U
� � FT. asCL
I am exempt under Sec. SIZE O
B.BP.C. for this reason ELECTRICAL =7 MOOD:
Date: 2"ITE?} O
...... 0
Signature Steel 8 Conduit Bonding
g Conduits, Conductors, Equipment TOTAL 428 95LLI
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATIONPLUMBING CL
428.95
I hereby affirm that I am exempt from the Contractor's Licenser�—
Law for the following reason (Section 7031.5, Business and P-Trap
Professions Code): Gas System M7_ _M�y�nI, as owner of the property, will do the plumbing and Anti-Syphon �y��X0001
electrical work. I,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL 4817 1 AM11.100
other work and the structure is not intended or offered l Y 1
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT nt TEL. ^�
the performance of the work for which this permit is issued l�q ^ ►
P P (PRINT)
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS R6_/ C L.'t r�_W,
Lender's Address \�
P.C.Fee EJ . Permit Fee d
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee vv
mechanical and plumbing construction,and hereby authorize Investigation Fee
representatives t is County to enter upon the above- Total Fee �j
�m ntioned pro rty inspection purposes.
7
Signature of pplic nt or Agent J Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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