HomeMy Public PortalAbout10342 KEY WEST ST_Swimming Pool__ W6RKERS1 C`O MPENSATION DECLARATION
4 sure o a c& that I haver ertComp ns consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) 76A20B
CE876(3/84)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
aFOR APPLICANT TO FILL IN BuDDaDING ._j �, _Yr- AJr
Certified copy is filed with the county building inspec- ARESS
tion department. BUILDING
ADDRESS �� Z 4' Wes/ LOCALITY / sT
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY �1/ ZIP CROSS ST. / 1C %�)G
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 one / TEL. C r USE ON�1 MAP
hundred dollars ($100)or less.) OWNER v` J Z vA >� N0J-77 ,S p� NO. /1-7-21
I certify that in the performance of th"or fo which this �/ �j �� SPECIAL
permit is issued, I shall not employ a y pers inlany mann er ADDRESS ` 3 5' 7— ^1- �L � �c� CONDITIONS
so as to become subject to the W ers'Co e sati ' aws. �J {�� DISTRICT STATISTICAL CLASS TYPE PROCE ED BY
P p CITY �$ C /� zip ��1 7r/ ,l CONST.
Datef-2941 Applican '✓ ARCHITECT OR TE i U CLASS NO.
NOTICE TO APPLICANT: If, aft making this Certificate of ENGINEER vf�/� N / j'
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS $
�� ®� 1
with comply with such provisions or this permit shall be �7 A FJ a1 TEL. U VALIDATION
deemed revoked. CONTRACTOR(/WAJ /5 ��/l/�/� NO.
LICENSED CONTRACTORS DECLARATION LIC.
ADDRESS NO.
I hereby affirm that I am licensed under provisions of Chapter 9 LIC. $
(commencing with Section 7000) of Division 3 of the Business CITY CLASS
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
FINAL
License Number Lic. Class SWIMMING OOL ` �yh DATEr
L.ff �d 6J v Z s 'p� (
Contractor Date SpA FINAL V
❑ SO. FT. �'
I am exempt under Sec. SIZE �J�� BY !W�_
B.&P.C. for this reason I }� 6 4 f2� A
ELECTRICAL (� �t� /� ,'I o',o � 4, ,� V
Si nature Date: Steel & Conduit Bonding 7 a
9 Conduits, Conductors, Equipment 8 z
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING .26423A
I hereby affirm that I am exempt from the Contractor's License a p�
Law for the following reason (Section 7031.5, Business and P-Trap
Professions Code): p V
a Gas System �
I, as owner of the property, will do the plumbing and Anti-Syphon Q 1.28-87
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 EE(
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT �/ TEL. G
the performance of the work for which this permit is issued (PRINT), ( lux NO �f411/ ,
(Sec. 3097, Civ. C.). �j
Lender's Name ADDRESS i 9 �i &W �: fl v
Lender's Address e�
P.C. fee$ `� Permit Fee . .
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical and -',umbing construction, and hereby authorize Investigation Fee / v t rl
repre '�tatives of this County to enter upon the above- Total Fee i o
men oned pray f nspection purposes.
VVignature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE