HomeMy Public PortalAbout9229 KEY WEST ST_Swimming Pool__ VlO�y''<EPS' COMPENSATION DECLARATION
I h,rei5y offi?'ii tat I have a certificate of consent to self
insure, or:, certificate of Workers' Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or a ct#rtified copy thereof (Sec. 3800, Lab. C.) 76A20B
�Y CE876(3/84)
Policy P� Company Fes-" COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed•with the county building inspec- ADDRESS rl.�
tion department. BUILDING 92ZJ�le,_-,7—
_(�.� p•�� ADDRESS /I/ LOCALITY
Date 3 '�� Applicant t - — NEAREST
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 TEL. -~ USE�7j�Q�NE MAP
hundred dollars ($100)or less.) OWNER NO. 287. 51 j NO.
I certify that in the performance of the work for which this / SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS 4 � CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TVE PROCESSED BY
CITY ZIP •,�
CLASS NO.
Date Applicant ARCHITECT OR TEL. t
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.gyp. $
t� COO
VALIDATION
deemed revoked. CONTRACTOR NO.G� Z /
LICENSED CONTRACTORS DECLARATION LIC.
ADDRESS L.4,s NO. !OZ
I hereby affirm that I am licensed under provisions of Chapter 9 LIC. $
(commencing with Section 7000) of Division 3 of the Business CITY Com'/``�i CLASS
and Professions Code, and my license is in full force and effect. DESCRIPTION OF WORK FINA241 a 7 A
License Number �85�0�-- Lic. Class�S3
syn^ SWIMMING POOL DATE DATEUIA , # 0 0 0,0 21 >ft�
SPA
Contractor t unVv"�" Date SO. FT. BY FINAL f;o o 8 4'7 9 O
0 1 am exempder Sec. SIZE 3 �o a - 81L79.1 0-'
B.3P.C. for this reason Date: ELECTRICAL
031 .0-86 w
Steel 8 Conduit Bonding 0-
Signature Conduits, Conductors, Equipment
SINGLE FAMILY s. Z
HOME OWNER-BUILDER DECLARATION PLUMBING 241 &8 A
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and P-Trap , �• #,o 0 0 0 0 3
Professions Code): Gas System
1, as owner of the property, will do the plumbing and Anti-Syphon � 0 2 9 5,5 0
electrical work. 1, or my employees with wages as their o a 2.9 5 5 0 c=>
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered O 31 08 6
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.).
Lender's Name UJ4,16 ADDRESS .
Lender's Address 94/ .
x1'4 1 L Permit Fee
I certify that I have read this application and state that the P.C. Fee$ V
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee
mechanic I and plumbing construction, and hereby authorize Investigation Fee
represe rives, c! his County to enter upon the above- Total Fee
menti d pr for inspection purposes.
-3
igna re Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE