HomeMy Public PortalAbout9160 EMPEROR AVE_Swimming Pool__ pp"p-
WORKERS'�COMF_NSATION DECLARATION
' I hereby affirm that I hove a certificate of consent to self f
�
'1.sure,_oya certificate ofWorkers' Compensation Insurance, APPLICATION FOR COMBINA ION SWIMMINGPOOL PERMIT
6r a certtf d copy�ereifSec 3800, Lab C ) 76A20B
Policy �Oy ,tompanyJ�,4T�;F� CE-875(11/81) COUNTY OF LOS ANGELES BUILDING AND SAFETY
7 Certified copy is heeby furnished
FOR APPLICANT TO FILL IN BUILDING
Certified cop is filed with the coun y building mspec_ ADDRESS
tion epar ent BUILDING
ADDRESS
ApplcaLOCALITY
Date ,L nt NEAREST r `,
G CITY /' CROSS ST
CERTI ICATE OF EXEI,APTION FROM WORKERS' SIZE OF ASSESSOkf
COMPENSA110N INSURANCE TRACT LOT LOT NO MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one TEL USE ZONE MAP
hundred dollars ($100)or less ) OWNER N NO
I certify that in the performa ce of the work for which this SPECIAL
permit is issued, I shall not e`r�ploy any person/in any manner ADDRESSCONDITIONS
so as to become ublec to th11 Wor e C m ensat o aws - D STRICT STATISTICAL CLASS TYPE— PROCESSED BY
CITY ZIP 011CLASS NO CONST
/ J ARCHITECT O
Date Applicc• �
ENGINEER NO
NOTICE TO APPLICANT If, r.`ier making this Certificate of Q
Exemption, you should bei +,a sublecl to the Workers' ADDRES VALUATION
\ Compensation provisions of ,�Labor Code, you must forth- VALIDATION
> with comply with such pro ons or this permit shall be TEL $
NO ?
deemed revoked
ri CONTRALTO J
zla22
LIC
LICENSED CONTR,',",ORS DECLARATION ADDRESS �ZQ. (� NO
I hereby affirm that I am licen�ed under provisions of Chapter 9 LIC $t
(commenting with Section 7000) of Division 3 of the BusinessCITY �i -1�r CLASS d
nd Professions Cod on Mice is in full force and eff�3 DESCRIPTION OF WORK V
'�1 FINAL ,
ense Number Lic Class SWIMMING POOL DATFJJ %2'9 b 3 A
`_; SPA FINAL / 2 V
ictor Dater �///
__4/,t!Z
am exempt under Sec SIZE �l/ BY 2ro'o 9 0 3>6 H
B&P C for this reason ELECTRICAL o o i a 9�'3 6 c�a Z
Date 07,25-84
Signature Steel & Conduit Bonding
Si -
9 Conduits, Conductors, Equipment = 2 9 6 4 ,4
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING tt o'o 00 o
I hereby affirm that I am exempt from the Contractor's License -31`3 7�
Law for the following reason (Section 7031 5, Business and P-Trap , ° ° 7 1 3/ V z
/ Professions Code) Gas System v 0725-84
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work 1,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered t
for sale (Section 7044 B&P Code) Swimming Pool Heater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TEL
the performance of the work for which this permit is issued (PRINT) NO ,
(Sec 3097, Civ C )
Lender's Name ADDRESS
r
A
dress
PC Fee$ �j Permit Fee
t I have read this application and state that the
mat orrect I agree to comply with all County
nd Stat Taws relating to building, electrical, Issuance Fee
nd plu bang construction, and hereb author'ze Investigation Fee
iv this County to enter upon he a a Total Feer fo i spechon purpoDate SEE REVERSE FOR EXPLANATORY
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