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HomeMy Public PortalAbout9021 EMPEROR AVE_Swimming Pool__ l WORKERS'COMPENSATION DECLARATION 7-- 'J -•.1^hereby affirm that I have a certificate of consent to self i„ure, oA#certificate of Workers' Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT or a_ certified copy thereof (Sec. 3800, L b. C.) 76A20B ��,, -0 7 �* d� CE-875(1 1/81) Poli y !o! ompany L �•>. COUNTY OF LOS ANGELES BUILD ND SAFETY Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING E�'I',�Certified copy is filed with the county building inspec- ADDRESS ` tion department.-7- BUILDING ADDRESS _� �J'G''�. LOCALITY Date Applicant NEAREST 4F or I CERTIFICATE OF EXEMPTION FROM WORKERS' CITY _ IP CROSS ST. 7 COMPENSATION INSURANCE SIZE OF ASSESSOR TRACT LOT LOT NO. MAP BOOK PAGE I PARCEL (This section need not be completed if the permit is for oneTEL. USE ZONE MAP hundred dollars($100)or less.) OWNER �1iG.- NO. NO. .Q© _ I certify that in the performance of the work for which this i SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS CONDITIONS so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROC SED BY CITY ZIP CONST. Date Applicant ARCHITECT TEL. CLASS NO NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER i' 'i.�J NO. ��U� 3 �V Exemption, you should become subject to the Workers' VALUATION Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or this permit shall be TEL $ to VALIDATION deemed revoked. CONTRACTOR _ LICENSED CONTRACTORS DECLARATION / �� IC. � I hereby affirm that I am licensed under provisions of Chapter 9 ADDRES '' O.!� `T' $ (commencing with Section 7000) of Division 3 of the Business CITYC ASS 0. and Professions Code,and my license is in full force and effect. � 0. DESCRIPTION OF WORK FINAL Leg , =:299,6A License Number Lic. Class( P P.ELECTRICAt( OOL y�� ,7 DATE o o'o'o Contractor �""�Date i FINA ` Jdg'l U � o =I am exempt under Sec. a � 7'2'b-8 4 B.&P.C. for this reason /13 Date: 42 '299,7A Steel & onduit Bonding SinnnturP �oiicl s, on actors, tquipment , o o'o 0'.0 3 SINGLE FAMILY ` HOME OWNER-BUILDER DECLARATION PLUMBING 2 a 1 [!. 3..6 3 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and P-Trap Professions Code): Gas System El I, as owner of the property, will do the plumbing and Anti-Syphon electrical work. I, or my employees with wages as their sole compensation,or a licensed contractor will do all MECHANICAL other work and the structure is not intended or offered for sale (Section 7044 B&P Code). Swimming Pool Heater CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for APPLICANTTEL.^ � the performance'of the work for which this permit is issued (PRINT) NO.y (Sec. 3097, Civ. C. , A Lender's Name ��� ADDRESS i Lender's Address J P.C. Fee$ 7I73 Permit Fee /J ! 1 certify that I have read this application and state that the above information is correct. I agree to comply with all County TO ordinances and State laws relating to building, electrical, Issuance Fee GC7� mechanical and plumbing construction, and hereby authorize Investigation Fee `�/J? r 61 represents Ives of this County to enter upon the'above- Total Fee 7' ment' property for inspection purposes. Signature of Applicant or Agent Ve SEE REVERSE FOR EXPLANATORY LANGUAGE