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HomeMy Public PortalAbout10360 KEY WEST ST_Swimming Pool__ WORKERS'COMPENSATION DECLARAioN .7 _4 / re affirm that 1 havecertificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec 3890,Sp)Z 76A20B 'CE -875 Policy NJ3 �JLwy Company •` COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING r� Certified copy is filed with th o building mspec- ADDRESS ,Q �tio dep invent BUILDING � �� ^ ^ .�/ ADDRESS LOCALITY Dat °� APPI t IC' r 1.+ NEAREST CER IFICATE OF EXEMPTION FROM WORKERS', CITY ZIP _ - CROSS ST COMPENSATION INSURANCE SIZE OF ASSESSOR TRACT LOT LOT NO MAP BOOK PAGE PARCEL (This section need not beicompleted if the permit is for one `� _S „E. TEL ! `i USE ZONE MAP hundred dollars ($100)or less.) OWNER �3�f V NO 7223•-1W NO- ,.26>14 1 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 d LL) �1 CONDITIONS so as to become subject to the Workers'Compensation Lawsb DISTRICT STATISTICAL CLASS TYPE PROCESSED BY CITY ZIP (� CONST Date Applicant -ARCHITECT OR TEL CLASS N / o NOTICE TO APPLICANT .If, after making this Certificate of ENGINEER NO �� / 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 $ © VALIDATION deemed revoked CONTRACTOR NO r LICENSED CONTRACTORS DECLARATION LIC ADDRESS Fj /� �J (/; NO I hereby affirm that I am licensed under provisions of Chapter 9 LIC 5 (commencing with Section 7000) of Division'3 of the Business 45�CITY ' >_ and Professions Code, and my license is in full force and effects "CLASS A �C DESCRIPTION OF WORK / License Number '�✓ Lic Class QFINAL , V r SWIMMING POOL • Z 1 2 f DATE 0 7 9,8 A IM Contract 96&4Date GO SPA FINAL �! # o 0 o o 2 1 U SQ FT CJ BY W El I SIZE am exempt under Sec 2.0 1 57.80 � B 8P C for this reasonELECTRICAL /� r 1 5'],8 0 Z - � o ;o i o Date Steel & Conduit Bonding �/�� 0 3 28-83 • Signature Conduits, Conductors, Equipment N SINGLE FAMILY , HOME OWNER-BUILDER DECLARATION PLUMBING I 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 1, as owner of the property, will do the plumbing and Anti-Syphon 0 7 9. 9 A electrical work I,or my employees with wages as their # o o o o o 3 sole compensation,or a licensed contractor will do all MECHANICAL other work and the structure is not intended or offered 0 25&00 for sale (Section 7044 B&P Code) Swimming Pool Heater CONSTRUCTION LENDING AGENCY to'o 2 5 8 0 0 v I hereby affirm that there is a construction lending agency for APPLICANT the performance of the work for which this permit is issued (PRINT) r "NO 13 28,-8,3 (Sec 3097, Civ C ) -� BQ Lender's Name_je(/t�nr/)t�I Lt�� �— ADDRESS / Lender's Address /} d S �V I certify that I have read.this application and state that the P C Fee$ Permit Fee , above information is correct I agree to comply with all County D S() ordinances and State laws re ting to building, electrical, Issuance Fee mechani I and plumbing co uction, and hereby authorize Investigation Fee F V rep'._ tives of this Co to enter upon the above- Total Fee mentro d property f tion purposes Si nature of Appli ant Lr Agent ate SEE REVERSE FOR EXPLANATORY LANGUAGE