HomeMy Public PortalAbout9949 DUFFY ST_Swimming Pool__ I
WORKERS COMPENSATION DECLARATION -
I hijreb thatr`l have a certificate of consent to,self
msure*,�k..a certift¢ate of,Workers' 'onipensat�an;ne%*'.nce, QP(PL�C.A p GH POR CGPA �p�J/�p P®p�J �t/170111�1►pUVJ�'pF1� ?00LPERMIT
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or a certified cery thereof (SeL3800, LobC. 7676A2013 - - „
�^�{ ,.r. . .. . CE876(3/84)
Polis N Com an �t70�✓7` COUNTY OF LO.S-AYVGELES BUILDIi�G. AND SAFETY
y e P Y
0 Certified copy is"hereby furnished.
FOR APPLICANT TO FILL.IN BUILDING
H Certified copy is filed with the county building inspec- ADDRESS
tion.departmeht. BUILDING
/r����� ADDRESS G/C/ \JT _ LOCALITY / Y
Date'? Applican - _ ^7 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITv�E/lif� z ZIP. q� /�0.: CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT T . LOT NO. MAP:BOOK PAGE. PARCEL
(This section'need not be completed Wthe permit is far oneUSE ZONE MAP
TEL: ,
hundred dollars ($100)or less.) OWNER ,� A NO. NO. j
J certify that in the performance of4the work for which-this 1 SPECIAL
P
ermit iu
s issued,.I shall not employ any person in any manner _ ADDRESS /"t.�. �• / CONDITIONS
so as to become subject:to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
t CITY ZIP' `./ v CLASS NO. CONST.'
J yC(1
Date Applicant 'ARCHITECT OR TEL,
NOTICE.TO APPLICANT:.If, after making, this Certificate of ENGINEER NO.
Exemption, you*.Should become "subject ..to -the Workers' VALUATION ALUATION
Compensation provisions of the Labor Code;•you"must',fortfi- VALIDATION
with comply with such provisions or this permit shall be �sAj./ i.e. TEL
CONTRACTOR 45 fL L�7 NO.GO $
deemed.revoked: -
LICENSED CONTRACTORS DECLARATION ADDRESS �! J LIC /� D
(;'hereby affirm that I am licensed uride'r provisions of Chapter 9 / LIC $ -
(commencing with Section 7000) of Division 3 of'the Business CITY' A &— CLASS, C�
and Professions Code,and my license-is-in full force and effect.
`� DESCRIPTION OF WORK FINAL t 40
'License Number 46 40�—' Lic Class SWIMMING POOL Q �• n`h DATE
S Y� a. _ t"
Contractor Date V` SPA 3 a
50. FT: it
FINAL
57/to :aa9
BY .. .
F am'exempt under Sec. SIZE `
B.&P.C_ for this reason
ELECTRICAL
Date:'.
Steel &Conduit Bonding = ( � CL
Signature Conductors, Equipment
Conduits, Co
SINGLE.FAMILY.'
HOME OWNER-BUILDER.DECLARATION
PLUMBING I
I hereby affirm that'l am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business.and p Trap
Profession's Code): `
- . .: .. Gas System ._ . ..
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. L, or my employees with wages as their..
F l rr
sole compensation or a licensed contractor`'will do'all. MECHANICAL a - ;•_
other work and the structure is not'intended or offered
for sale (Section 7044 B&P Code) Swimming Pool Heater - f' .33' 0
CONSTRUCTION LENDING AGENCY • -
I hereby affirm that there is a construction lending agency for APPLICANT TEL
the performance of the,
Sec. 3097, Civ. C. ark for which this permit is issued (PRINT) f NO. �� ''t t
Lender's Name ) � D
rADDR /v
Lender's Address Permit Fee � .: r 4=�I certify that'I have read this application and statethat the
above information iscorrect. I agree to comply with all County ordinances and State laws relating to building,; electrical; Issuance Eee
mechanical and plumbing con'struction, and herebyauthorize nvesgaoe
representatives o is County to enter upon the above- Total Fee - _ v®
tioned�rop Tty nspection purposes.
ignature of ppliApnt or Agent DateSEE REVERSE FOR EXPLANATORY LANGUAGE