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HomeMy Public PortalAbout10306 KEY WEST ST_Swimming Pool__ WOP.KERS'COMPENSATION DECLARATION I het y-affirm that I have a certificate of`consent to`self insurel,i n certificate of Workers' Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT or a certifi1 ` copy thereof (Sec. 3800, Lab. C.) 76A20B 136 , )tl F�MDA17- CE876(3/84) Policy o. (J o pant' COUNTY OF LOS ANGELES BUILDING AND SAFETY F1 Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN I Certified copy is filed with the county building inspec- ADDRESS tion department. BUILDING 4 LOCALITY ADDRESS Date 4-L--90 Applicant NEAREST CERTIFICATE-OF EXEMPTION FROM WORKERS' CITY ZIP CROSS ST. O COMPENSATION INSURANCE SIZE OF ASSESSOR TRACT LOT LOT NO. MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for oneT _EL. SE ZONE MAP p 1 hundred dollars(=100)or less.) OWNER U20 NO. NO. I f' I certify that in the performance of the work for which this G SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS © G. �}�5 CONDITIONS so as to become subject to the Workers'Compensation Laws. QQ DISTRICT STATISTICAL CLASSe TYPE PROCESSED BY CITY ZIP l7(JQ / CONST. fffAAA Date Applicant ARCHITECT OR TEL. O CLASS NO. i / NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. 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 /1,/// ''�• TEL. / $ VALIDATION deemed revoked. CONTRACTOR �W/ JL5 NOZS,7Z2�I LICENSED CONTRACTORS DECLARATIONADDRESS LIC.. jf/ ,5//n�-� �, NO49Z ' hereby affirm that I am licensed under provisions of Chapter 9 LIC. S (commencing with Section 7000) of Division 3 of the Business CITY 5A A48/0//yeZ_ CLASS G55 23 and Professions Code,and my hcen§e is in full force and effect. DESCRIPTION OF WORK �/►••`�p FINAL. V!a Q.. License Number ��5/OZ Lic. Class t _7 SWIMMING POOL S f+� a qr. a �� DATE q Q +y'} Contractor Lir lbel-SDate 2- /0 SPA � FINA k 7 d�Vm6( SQ. FT. •4 I am exempt under Sec. SIZE )A� , . O B.&P.C. for this reason ELECTRICAL 1C4r TmA& U Date: ( OAF Steel & Conduit ng Signature Conduits, Conductors,, Equipment W SINGLE FAMILY HOME OWNER-BUILDER DECLARATION PLUMBING , I hereby affirm that I am exempt from the Contractor's License 2 ITEM z Law for the following reason (Section 7031.5, Business and P-Trap Professions Code): Gas System TOTAL 526.27 I, as owner of the property, will do the plumbing and Anti-Syphon OECK ' 5,276.27electrical 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 m0 for sale (Section 7044 B&P Code). Swimming Pool Heater CONSTRUCTION LENDING AGENCY F -= 8/ 9/,Q,9 I hereby affirm that there is a construction lending agency for APPLICANTL e� p� the performance of the work for which'this permit is issued (PRINT) S 49 1 1 AM10:1.7 (Sec. 3097, Civ. C.). JPIA& /A Lender's Name ADDRESS G•JA5 M5 t Lender's Address / 0 P.C. Fee$ / a Permit Fee �3(/ Y 1 certify that I have read this application and state that the above information is correct. I agree to comply with all County /r� • �� ordinances and State laws relating to building, electrical, Issuance Fee mechanical and plumbing construction, and hereby authorize Investigation Fee ff11 representatives of this County to enter upon the above- Total Fee © e V me tioned pro rt f reinspection purposes. gnature of A=tor Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE