HomeMy Public PortalAbout10243 OLIVE ST_Swimming Pool__ WORKERS'COMPENSATIn N DECLARATION
hereby affirm that I ha e r certificate ome of tionconsent to Self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or o certificate of Workers'Compensation Insurance '
or p h rf(Sec 380 b. C.) 76A20B
CE-875(11/81)
Poli y any COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished. 1--44—VS—
yg P FOR APPLICANT TO FILL IN BUILDING
�ertified copy is filed with the ount buil 'n ms ec- ADDRESS
"C` tion epa tmen. BUILDING
Dat ApplicanOCALITY
t ADDRESS NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS,
ORKERS I CITY q I IP CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the pormilt is for one nJ TEL. USE ZONE MAP
hundred dollars($10>))or lass.) OWNERJ41 V (� t NO. NO. ��
1 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 J (SWCONDITIONS
so as to become subject to the Workers'Compensation Laws. 1 "1519TRIC!" STATISTICAL CLASS I TYPE PROCESSED BY
CITY ZIP CLASS NO. CONST.
Date Applicant ARCHITECT O TEL.''cc
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NOl�?
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS/
with comply with such provisions or this permit shall be to $
VALIDATION
deemed revoked. CONTRACT VIAL✓ 1LJ
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS LIC $
(commencing with Section 7000)of Division 3 of the Business CITY �/�1 CLASS
and Professions C d and my lice a is in full force ancJ�ffg t.
(n/�,.l DESCRIPTION OF WORK FINAL �^ I _,,.'
License Number 0 Lic. Classa SWIMMING POOL DATE J 01/LIL , at
at
Contractora Date v SPA FINAL
El SQ. FT. BY C cs 6. :{ / M
I am exempt under Sec. SIZE 911.
B.&P.C. for this reason Date: ELECTRICAL
Signature Steel&Conduit Bonding
9 Conduits, Conductors, Equipment
SINGLE FAMILY
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
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. 1,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 LLQ'
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICAN TEL.
the performance of the work for which this permit is issued (PRINT NO. 0i /7
(Sec. 3097, iv. C.).
Lender's Nam P� ADDRESSg!(j2tL n;x,
Lender's Address
Permit Fee
I certify that 1 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 45V
mechanical lumbing c nstruction,and hereby authorize Investigation Fee ®�
re res t Ives this C unty to enter upon the above- Total Fee
mentio pro rt r r i pection purposes.
Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE—