HomeMy Public PortalAbout9228 LONGDEN AVE_Swimming Pool__ ;,'COMPENSATION DECLARATION
hereby ai y. that I have��- certificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
ins4e,or .y`iifica?e of Workers'Compensation Insurance,
or as ' i�Prsp,cop thereof(Sec. 3800 . C.) 6A20B
rv/7 �1�+ '
Polidy 1 ompany CE876(3/84) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified co is filed with the co nt ryldin ins ec- FOR APPLICANT TO FILL IN BUILDING (l
copy G g p ADDRESS d
tion epar m t BUILDING
1/`� ADDRESS "`7 0``x'3 LOCALIT
Date App I i ca nt NEAREST Oak
CERTIFICATE OF EXEMPTION FROM WORKERS' CIT IP CROSS ST.
SIZE OF ASSESSOR
COMPENSATION INSURANCE
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed If the permit is for one TEL. USE NE MAP
hundred dollars($100)or less.) OWNER O. NO.
I certify that in the performance of the work for which this �J / SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS d•2C CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CI ZIP CONST.
Date Applicant ARCHITECT TEL CLASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO .Z01L•/ t
Exemption, you should become subject to the Workers' //�� d VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS •1J�V % �/ ,`
with comply with such provisions or this permit shall be CONT NI✓ $ U VALIDATION
deemed revoked.
LICENSED CONTRACTORS DECLARATION II �. LI
ADDRES l� ���' J
I hereby affirm that I am licensed under provisions of Chapter 9 LIG $
(commencing with Section 7000) of Division 3 of the Business CITY ��� CLASS
and Professions C d nd my license is in full force and effect. DESCRIPTION O ORK
J�/ Q FINAL
License Numb (J Lic. Class CJ SWIMMING POOLCl
DATE
JContracto Date SPA FIN
SQ.FT. B
❑ 1 am exempt under Sec. SIZE S i 4 7 9.� 1111� 0:B.BP.C. for this reason ELECTRICAL I o 0 6 a
Date: � •0 0 0 (j 8,0 5
Signature Steel 8Conduit Bonding
Co duits, Conduors, EquipmentSINGLE FAMILY 06, 1 0_8 6 Z
HOME OWNER-BUILDER DECLARATION PLUMBING ►
Law for the following reason (Section 7031.5, Business and P-Trap
Professions Code): Gas System # 0 0 0 0 0 3
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I,or my employees with wages as their 1 - 239.26
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered 0 o 2 3 9.2 6
for sale (Section 7044 B&P Code). Swimming Pool Heater 0 610-86
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT
the performance of the work for which this permit is issued (PRINT) Np4 ,
(Sec. 3097, Civ. C.),n )
Lender's Name r ADDORS) C.I—)
Lender's Address
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 plumbing construction,and hereby authorize Investigation Fee
represent of this County to enter upon the above- Total Fee 2 ,6
mentio d pro t for inspection purposes.
Sign ure of Applico or gent Date SEE REVERSE FOR EXPLANATORY LANGUAGE