HomeMy Public PortalAbout10708 MILOANN ST_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
I hereby afb+rm thatil have a certificate of consent to self
ins0re, or a certificate of Walkers'Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or a certified copy thereof(Sec. 3800, Lab. C.) 76A20B
Policy No. CE-875(11/81)Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING ryo e
Certified copy is filed with the county building inspec- ADDRESS
tion department. BUILDINGi
ADDRESS � , LOCALITY
Date Applicant a NEAREST r
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY t ZIP CROSS ST.
COMPENSATION INSURANCE SIZE r $Cr?: ASSESSOR
TRACT LOT_i J �() LOT NO. �j MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one mTE��Ipp pp "��i�1r U ZQNE� MAP ?
hundred dollars($100)or less.) OWNER ' 6 Nv7Ip'�7aZ i y/ NO. /C US
I certify that in the performance of the work for which this SPECIAL
perrait is issued, I shall not employ any person in any manner ADDRESS Q i CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
/ + CITY 'y ZIP CONS.
Date_`A1,7 �� Applicant (� '/N7Lr� ARCHITECT OR TEL. ]mss CLASS N .
NOTICE TO APPLICANT: If,pl ant this Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS VALIDATION
with comply with such provisions or this permit shall be //�� A TEL e �'-- $ ® v
deemed revoked. CONTRACT /y C fO CUGn�if / GgNO.
LICENSED CONTRACTORS DECLARATION S / LIC.,w
ADDRESS Jj - NO.03
1 hereby affirm that I am licensed under provisions of Chapter 9 LIC. $
(commencing with Section 7000)of Division 3 of the Business CITY CLASS
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK FINAL ,S
Ef
License Number Lic. Class SWIMMING POOL DATE
10
Contractor Date of
SPA e FINAL
SIZE ® o /® � $ // BY ` �2 0 Jam.8 A AL
I am exempt under Sec. O #A
B.&P.C. for this reasonELECTRICAL o 0,0 0 03
�
Date: Steelonng I o 1 0 810 0
Signature Conduits, ConduConduit Bctors�Equipment 8
SINGLE FAMILY 1 00 17 Z3 T1
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
19 IC71 1, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I,or my employees witWwages 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 ` STEL.
the performance of the work for which this permit is issued (PRINT)/_)EIVIVis T,Gl9.L/r SRI NO. ,�Q
(Sec. 3097, Civ. C.).
Lender's Name / ADDRESSe
.E � C a
Lender's Address 0
P.C.Fee$ Permit Fee � 0
1 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 eS
mechanical and plumbing construction,and hereby authorize Investigation Fee �0
representatives of this County to enter upon the above- Total Fee /09, OD
mentioned property for inspection purposes.
Signature of phcant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE