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HomeMy Public PortalAbout5308 NOEL DR_Swimming Pool_5/18/1983_ WORKERS COMPENSATION DECLARATION hereby affirm that 1 have a certificate scion Ins to self -APPLICATION FOR COMBINATION SWIMMING POOL PERMIT insure or a certificate of Workers Compensation Insurance or a certified copy there (Sec 3800 Lab C ) 76A20B No51414S CE 875(11/81) Policy mpany i$ oCOUNTY OF LOSANGELESBUILDING AND SAFETY Certified copy is hereby furnished IvyFOR APPLICANT TO FILL IN BUILDING Certified copy is filed with the county building inspec ADDRESS tion department BUILDING ADDRESS . AJC)W__ Or- LOCALITY S O N Date 5--�n Applicant .-+ NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS CITY I �G Ze ZIP ALI 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 f1 TEL 6 �Q USE ZONE MAP hundred dollars($100)or less) OWNER &VD NO?ia 7 �+I NO 1 certify that in the performance of the work for which this A, SPECIAL permit is issued I shall not employ any person in any manner ADDRESS �^1 /" • NO 0�-• CONDITIONS so as to become subject to the Workers Compensation Laws CITY L:I ZIP 11-72(0 PVALUATION /ICT STATISTICAL CLASS CONST PROCESSED BY Date Applicant ARCHITECT TEL CLASSNONOTICE TO APPLICANT If after making this Certificate of ENGINEER NOExemption you should become subject to the Workers ADDRESS Compensation provisions of the Labor Code you must forth p '7� VALIDATION with comply with such provisions or this permit shall be CONTRACTOR F PacLS NO Z�' s ( ✓ 0©� deemed revoked LICENSED CONTRACTORS DECLARATIONLIC ADDRESS$�Q(o JL �(./►9 �✓/1e.� NO S�aS(O Z I hereby affirm that I am licensed under provisions of Chapter 9 LIC $ (commencing with Section 7000)of Division 3 of the Business CITY CLASS f--S3 >' and Professions Code and my license is in full force and effect :DE IL �'6�I�Z Lic Class /� FINAL / ► O L cense Numbers SWIMMING:P00L DATE ^r�r�� V 1 Q 1 P4 ♦ Ot: Contractor(! ` ` oo`S Date (L S-10 gS SPA FINAL �'0 S A 0I am exempt under SecSIZE BY 0 0 0 0 2 1 d N B&P C for this reason ELECTRICAL 2 0 0 8 4,7 9 Z Date Steel &Conduit Bonding o so 0 r ( 7 9 mi Signature Conduits Conductors Equipment SINGLE FAMILY 0 5 18-03 HOME OWNER BUILDER DECLARATION PLUMBING r 2 0 7 6 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 i `#` 0 0 0 0 0 3 Professions Code) i Gas System r I as owner of the property will do the plumbing and Anti Syphon 2 - 29550 electrical work I or my employees with wages as their sole compensation,or a licensed contractor will do all MECHANICAL i° ° 2 9 5. "10 C6 other work and the structure is not intended or offered for sale (Section 7044 B&P Code) Swimming Pool Heater 0 5 1 8-8 3 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 Z$S-Zzb� Pool 3097 Civ C ) F� � Lender s Name ADDRESS �/ I/LTi T(lyt-C,7 i Lender s Address CA PC Fee$ Permit Fee 0.0 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 I Issuance Fee mechanical and plumbing cohstruction and hereby authorize Investigation Fee representatives of County to enter upon the above Total Fee menfio d pr e y f inspection purposes 5 0 Signator ant or Agent D to SEE REVERSE FOR EXPLANATORY LANGUAGE