HomeMy Public PortalAbout10405 KEY WEST ST_Swimming Pool__ WORKERS' COMPENSATION L1CLARATZN
herebo,a certificate
fica I"have r cerTificme of. consent to self APPLICATION FOR COMBINATION SWIMAING POOL PERMIT
insure, or a certificate of Workers' Compgensation Insurance, '
or a certified copy thereof (Sec 366, Lot, C ) 76A20B --
CE-875(1 1/81)
•
Policy No Company l��v/�11 �' COUNTY OF LOS ANGELES BUILDING AND SAFETY
jCertified copy is hereby furnished
_FOR APPLICANT TO FILL'IN BUILDING ' a
Certified copy is filed with the county builds mspec- ADDRESS i
tion depgriment BUILDING /n
/ ADDRESS / t LOCALITY
Dare ��
Applicant--G7 t NEAREST 1
CERTIFICATE 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 be completed if the permit is for one 1 TEL US ZO E MAP J�
hundred dollars (;100)or less ) I FADDRESS
,1'0 NO NOI certify that in the performance of the work for whichthis ,, tt SPECIAL
permit is issued, I shall not employ any person in any manner V CONDITIONS
so as to become subject to the Workers'Compensation Laws , -` DISTRICT STATISTICAL CLASS TYPE PR SSED BY
CITY � xIP (/ CONST
.Date Applicant ARCHITECT OR TEL CLASS NO /
NOTICE TO APPLICANT If, after making this Certificate of ENGINEER NO `J U �✓
Exemption, you should become subject to the Workers' VALUATION 1
Compensatidn provisions of The Labor Code, you must forth- ADDRESS TEL ; VALIDATION
with comply with such provisions or this permit shall be
deemed revoked CONTRACTO NO
LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO LIC ` $
(commencing with Section 7000) of Division 3 of The Business CITY CLASS �'1 $9 8 A
and Professions CNand license is in full force and effectDESCRIPTION OF WORK T` FINAL' ` # 0 0 0 02 10.7/License,NumberLie Class SWIMMING POOL 1 DATE I 84,79
O
SPA F-
Contracto Date , SO FT car BNA / o o o 8 p,`]9 c.=) V
El .I am exempt under Sec SIZE T \ /( Q U,2 2,7 8'5 d
' B&P C for this reason ELECTRICALS`. _ � ,.
Z
Date
Signature
Steel & Conduit Bonding
g Conduits, Conductors, Equipment
SINGLE FAMILY z 89,9A
HOME OWNER-BUILDER DECLARATION, PLUMBING w # o o e'0 0 3
1 hereby affirm that I am exempt from the Contractor's License , I0 2 Q rj 8
Law for the following reason (Section-7031 5, Business and 0•o
Professions Code) a P-Trap
Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon y OIL 22 =85
electrical work I, or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered -
for sale (Section 7044 B&P Code)- Swimming Pool Heater ;
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TEL
the performance of the work for which this permit is issued (PRINT) _ NO ,
(Sec 3097, Civ C ) I
Lender's Name ADDRESS
Lender's Address -�S' Ga ,
PC Fee$ 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 _ l OrS�
ordinances and State laws relating to building, electrical, Issuance Fee -
mechanical and plumbing construction, and hereby authorize Investigation Fee
16'n,tioned
esentatives of this County to enter upon the above- Total Fee
prop for inspection porpos Ft
Signature'of Applicant or Agent Date ;SEE REVERSE FOR EXPLANATORY LANGUAGE i