HomeMy Public PortalAbout10130 OLIVE ST_Swimming Pool__ .r �11WORKERS'COMPENSATION DECLARATION p�® ,�+ y� n� n[� n n
I insure,
n n'. that I have a certificate of consent to self ,yL PPLIC �� N FOR COMBINA ll CH SWI PA�p S l 001 [PER �U
insure, 3r a certificate of Workers'Compensation Insurance, 6� LT" 6'�
or a certified copy thereof (Sec. 3800, Lab. C...) 76A20B
Pomq / Cmpanya b. ;6&x �
CE876(3/84) COUNTY OF LOS ANGELES BUILDING AND SAFETY `
Certified copy is hereby furnished.
ert'fie copy is filed t ount buildin ins ec- FOR APPLICANT TO FILL IN BUILDING Oi a, ,�
Y g P ADDRESS I c�I I w --.,
tion a artmenf. BUILDING IO 2 ` ® ' 4
ADDRESS J(/ LOCALITY
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FVMWRKERS' CITY ZIP CROSS ST. J L o I
COMPENSATION INS SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed If the permit Is for one TEL. pl q�71(�f',A USE ZONE MAP
hundred dollars($100)or less.) OWNER NO.dP b Ml`I' NO.
1 certify that in the performance of the work for which this3 O �j `` SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS I(�f °t `c-Z / CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP � CONST.
NOTICE TO APPLICANDate T: If, after making this Certificate of licant ARCHITECT ORjT�l� NC0S-1 CLASS N /
ENGINEER 11 / 1V/
Exemption, you should become subject to the Workers' ADDRESS ,3 Q�I:�J V AU VALUATION
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be ``fi� TEL. n 11 (� VALIDATION
deemed revoked. CONTRACTO&(.t; C�(AJ NO."N"yu? $ u� �I(A
LICENSED CONTRACTORS DECLARATIONLIC. ��
ADDRES `
I hereby affirm that I am licensed under provisions of Chapter 9 �J Z(f NO.
$
(commencing with Section 7000)of Division 3 of the Business " p� LIC. t
and Professions C d and my is nse is in full force and ect. CITY ji- N � CLASS C�3--
DESCRIPTION OF WORK FINAL _�
License N ber Lic. Class C SWIMMING POOL DATE
1 SPA
Contra 3✓ Date F Q
SFT. ed
I am exempt under Sec. SIZE
B.&P.C. for this reason ELECTRICAL CA
Date: u
Signature Steel &Conduit Bonding
Conduits., Conductors, Equipment
SINGLE FAMILY �9 Z
HOME OWNER-BUILDER DECLARATION PLUMBING e
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
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I,or my employees with wages 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 APP(1CAN; N�
the performance of the work for which this permit is issued PRINT
(Sec. 3097, Civ. a A �'
Lender's Nam / C/�I,,
ADDRESS ,�I, �
Lender's Address /
, a C�lp
I certify that I have read this application and state that the P.C.Fee$ 7 Permit Fee -
above information is correct. I agree to comply with all County
ordinanc d State laws relating to building, electrical, Issuance Fee
mecha ical an tubing construction,and hereby authorize Investigation Fee
representatives of is County to enter upon the above- Total Fee
mentione roper or inspection purposesr-; k
Signatu a of Applicant or Age t Date SEE REVERSE FOR EXPLANATORY LANGUAGE