HomeMy Public PortalAbout9479 OLEMA ST_Swimming Pool__ WOkKEPS'COSAP;NSATION DECLARATION
k p ent to lfirtr _ or 4 certificate ofWorkes' Compensatie of on Insurance, APPLICATION
FOR
COMBINATION SWIMMING POOL
WIMMING ®®L P6RPMV
or a certified copy thereof (Sec. 300, Lab. C.) 76n20s
ty_N rjn 19�� CE876(3/84)
Policy No. r Company 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
tion department. BUILDING Q ,r A
ADDRESS -{`i 0 LE ►F LOCALITY
Date � 4 Applicant 1 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY T' {e, � ZIP gl"�aO CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
(This section need not be completed if the permit is for one TRACT LOT LOT NO. MAP BOOK PAGE PARCEL��AA
hundred dollars($100)or less.) OWNER �� Ki s�� NO.28tj-� USE O OP
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 5• A r"F• CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT fTATISTICAL CLASS TYPE PROCESSED BY
CITY Ie C. ZIPr, CLASS NQ-� CONST.
Date Applicant ARCHITECT OR !\
TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. J
Exemption, you should become subject to the Workers' ADDRESS VALUATION
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be TEL. VALIDATION
deemed revoked. CONTRACTOR NO.Z -=4p( $ 10 OIaC--)
LICENSED CONTRACTORS DECLARATION �j LIC.
ADDRESS T NO. SIOZ
I hereby affirm that I am licensed under provisions of Chapter 9 $
(commencing with Section 7000)of Division 3 of the BusinessLIC'
and Professions Code,and my license is in full force and effect. CITY -50-*_C0D.br jet CLASS C,-53 7 8 4 4 A
DESCRIPTION OF WORK FINAL
`` aL 0 0 0 0
License Number_S ��Z Lic. Class C`�3 SWIMMING POOL f71 i�i�r � 2
f `�- Q(.� DATE ( o - 6&05
' SPA
Contractor Date 50. FT. q (�
Elam exempt under Sec. SIZE 30 Y �� / o 0 0 6 0 5 u in:
B.&P.C. for this reason ELECTRICAL 09.04-87 �0
Date: S
W
Signature Steel &Conduit Bonding n
Conduits, Conductors, Equipment N
SINGLE FAMILY 97811,5A
Z
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License # 0 0 0 0 0 3
Law for the following reason (Section 7031.5, Business and P-Trap
Professions Code): Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon I o239,26
electrical work. I,or my employees with wages as their - 239265
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered 09.04-87
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 B V TEL.
the performance of the work for which this permit is issued (PRINT) NO.
(Sec. 3097, Civ. C. .A
Lender's Name ��+�- ADDRESS 4
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 CD`S�
ordinances State aws relating to building, electrical, Issuance Fee
mechanica d i g construction, and hereby authorize Investigation Fee
represent es fi County to enter upon the above- Total Fee
m do r rt f r inspection purposes
0 T-7
Signatur of scant or Agent ate SEE REVERSE FOR EXPLANATORY LANGUAGE