HomeMy Public PortalAbout9107 HERMOSA DR_Swimming Pool__ 'IT)pgER"COMPENSATION DECLARATION
Thereby c firm 'orhat t .have a Certificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a'<eitificate of Workers'!Compensotion Insurance,
or a c fr,tifted copy thereof (Sec. 3800, Lab. C.) 76n206
CE876(3/84)
Polley RiaM�PIompany C./1/f •- COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspec- ADDRESS '
tion department. BUILDING /
ADDRESS LOCALITY 'Itnal CIA
Date Applicant -7,30 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY Cr(/1�G� ( ZIP /(JL/ ASSESCROSSOR
COMPENSATION INSURANCE SIZE F ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit Is for one TEL. �i US ZONE MAP _
NO -D I NO. t
I certify that in the performance of the work for which this ' SPECIAL
hundred dollars ($I00)or less.) OWNER JIM
permit is issued, I shall not employ any person in any manner ADDRESS I CONDITIONS
so as to become subject to the Workers'Compensation Laws. - DISTRICT STATISTICAL CLASS TYPE- PROCESSED BY
CITY ZIP .� CON
Dote Applicant
ARCHITECT OR TEL ` CLASS NO. s�
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO, J
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, y ADDRESS
omit shall
forth- ^ 0,00 � VALIDATION
with comply with such provisions or this permit shall be IN�Y�. _ f i'/ (/ F ,
deemed revoked.- CONTRACTO r`G7 _
LICENSED CONTRACTORS DECLARATION ADDRE GRO� �� LINOC.
U .
I hereby affirm that 1 am licensed under provisions of Chapter 9 LIC � f �0 8 9.3 A
(commencing with Section 7000) of,Division 3 of the Business .CITY �, - CLASS
and Professions Code,ond'my license is in full force and effect. ...1 i
# . . . . 2J
�E^� - DESCRIPTION OF WORK rFINA
INAL
License Number 0 /1 Lic Class(..! _,211 SWIMMING POOL � ATE _ , ( �e e 3 Q.5 9
//�CC SPA yContra<torO r Date SSPQ. FT. Y �j Q, rj 9.� 2
❑ I am exempt under Sec, SIZE I n_1 , a 8 0
B.&P.C. for this reason ELECTRICAL �,a,.- i U
Dme: - ' �� �089,4A OfF
Signature Steel &Conduit Bonding U
9 Conduits, Conductors, Equipment FR— �# e e e e e s3 d
SINGLE FAMILY . . I • � r2 b 7 6 <n
HOME OWNER-BUILDER DECLARATION PLUMBING I t e'e 12 67 6 5' Z
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business andP-Trop Lr/(_ I I Q 1 ,11 't 8 8
Professions Code):' Gas System
AFL-�Jqd�/
❑ y
I, as owner of the property, will do the plumbing and Anti-Syphon
electricol 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 LId
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT
the performance of the work for which'this permit is issued (PRINT
(Sec. 3097, Civ. C). .
Lender's Name ADDRESS IF
Lender's Address -
• P.C.Fee S 3�L Permit Fee
I certify that I have rend this application and stale that the /1
above information is correct. I agree to comply with all County MIS-6
6
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical and plumbing construction, and hereby authorize Investigation Fee
representatives of this County to enter upon the above- I Total Fee
�IAppliconl
rty for inspection purposes.
or Agent Dote SEE REVERSE FOR EXPLANATORY LANGUAGE