HomeMy Public PortalAbout10380 KEY WEST ST_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self APPLICATION FOR COMMNATPd�N (SWIMMING POOL PERMIT
insure, or a certificate-of Workers' Compensation Insurance,
oro�cgrtifiei�copy the�o�f(Sec 3800, Lob. C.) �"7g6�A2�0B(3/84)
Po`tico.�t r company / O COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
SS10,3 O vv S
Certified copy is filed with the county building inspec- ADDRESS10,390 AeV
tion department. BUILDING
ADDRESSAow AW LOCALITY
Date Applica NEAREST
CITY ZIP CROSS ST.
CERTIFICATEOF XEMPTIOIN FROM
INSURANCE WORKERS'
SIZE OF ASSESSOR 110P.5' PAGE PARCEL l� J
TRACT LOT LOT NO. MAP BOOK cc��
(This section need not be completed if the permit is for one TEL. USE ZONE MAP
hundred dollars($100)or less.) OWNER NO. NO.
I certify that in the performance of the work for which this A SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS /V/ CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIPCONST.
Date Applicant ARCHITECT OR TEL.
CLASS,NO.
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
�jj---- $ , y,�y�r11 VALIDATION
with comply with such provisions or this permit shall be CONTRALTO No6E.�•,7 C/C�CJ"��
deemed revoked.
LICENSED CONTRACTORS DECLARATION ADORES c. SOS _
I hereby affirm that I am licensed under provisions of Chapter 9 gN&�q LIC. $
(commencing with Section 7000) of Division 3 of the Business CITY,�T� CLASS
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK Ir 1I FINAL
License Number Lic. Clas SWIMMING POOL ,l(L��=..11I DATE
SPAContract�T Date SQ. FT. ' FINAL
I am exempt under Sec. SIZE ,y BY O
B.&P.C. for this reason
ELECTRICAL
O
Date: f-
Steel &Conduit Bonding U
Signature Conduits, Conductors, Equipment LU
SINGLE FAMILY _ n'
HOME OWNER-BUILDER DECLARATION PLUMBING N
I hereby affirm that I am exempt from the Contractor's License ® si •t -11r
z
Law for the following reason (Section 7031.5, Business and
Professions Code): P-Trap 3
Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon _
electrical work. I,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL A"-"CT°a
other work and the structure is not intended or offered _
for sale (Section 7044 B&P Code). Swimming Pool Heater
i
CONSTRUCTION LENDING AGENCY C + '. 1 I E3°i'_
1 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. I'J€ iL --sem � --.�.f
(Sec. 3097, Civ. C.). ,
Lender's Name � •.t" �' �- .
�t�'II+��
ADDRES g
UnH
Lender's Address �p
P.C. Fee$ � •O Permit Fee �Jt„�' / •
I c`brtify that I have read this application and state that the
above information is correct. I agree to comply with all County �� �� Iti;lrl_;tl?q�} ,r �.�• f
ordinances and State laws relating to building, electrical, Issuance Fee +
mechanical and plumbing construction, and hereby authorize Investigation Fee �' _;� ( ;'° ;;,
rel,es ntatives of is County to enter upon the above- Total Fee • 4't'`' All °_-��
ntio ed prope y r inspection purposes.
Signature of pplicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE