HomeMy Public PortalAbout10526 OLIVE ST_Swimming Pool__ WORKERS'COMPENSATION DECLARA-�ION 11
hereby affirm that I have certificate of consent to self , APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers'
p
kers'Com ensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.) 76A20B
W N�3- e(p�e� 'CE-875(11/81) .
Policy No. Company�2e+koati COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING [ 7 ` G
Certified copy is filed with the county building inspec- ADDRESS V
tion department. BUILDING .-
ADDRESS C> �- �.I Ile LOCALITY �L 7 b (/
Date ^2'�3 Applicant CITY 1,em le_ ei ZIP 9 1 7 $0 CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF ASSESSO
COMPENSATION INSURANCE TRACT LOT LOT NO. AP BOOK PAGE PARCEL
M
(This section need not be completed if the permit is for one /� TEL. USE ZONE MAP
hundred dollars($100)or less.) OWNER PD✓LG�'1 NO. NO.
I 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 1052- 42 0L.!VL- CONDITIONS
so as to become subject to the Workers'Compensation Laws. T /J ISTRICT STATISTICAL CLASS TYPE PROCESSEIBY
CIN f� tCY"1 �� r� � ZIP g 9vCONST.Date Applicant ARCHITECT OR TEL, CLASS NO.NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. ' s
Exemption, you should become subject to the Workers' B rVALUATION ,.,A�
Compensation provisions of the Labor Code, you•must forth- ADDRESS / TEL J�� VALIDATION
with comply with such provisions or this permit shall be CONTRACTOR L NO. 5•
deemed revoked. Q�y /
LICENSED CONTRACTORS DECLARATION ADDRESS (�pO�j % L&ftTunz NO. `J.S 10Z
I hereby affirm that I am licensed under provisions of Chapter 9 LIC. $
,(commencing with Section 7000) of Division 3.of the Business CITY C m ft1 Go-br{e-'1 CLASS C S 3
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
n .rte FINAL U
Lic17, ense Number Igs l L)Z Lic. Class eSWIMMING POOL DATE ►
O t�
Contracto
P 3 Date Z 83 I SPA IF V
SQ.FT.
F-1I am exempt under Sec. SIZE 3� BYE x(I.96- A
B.&P.C. for this reason ELECTRICAL ;{ o o a o 2 1 Z
1 7-
/
Date: y
Steel&Conduit Bonding ,2'° ° 6 2.4 8
.SINGLE FAMILY
Signature Conduits, Conductors, Equipment oo a 6 2 4 8.6
'
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License 0 0.9 2-33
Law for the following reason (Section 7031.5, Business and P-Trap s
Professions Code): Gas S stem "4 964 A
Y
F11, as owner of the property, will do the plumbing and Anti-Syphon , 0 0 0 0 0 3
electrical work. I,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL 2 - 220.50
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater ° 0 2 2 0.5 0_
c.
CONSTRUCTION LENDING AGENCY 0 0.92-83
1 hereby affirm that there is a construction lending agency for APPLICANT L.
the performance of the work for which this permit is issued (PRINT) �1� 6 p NO. ,
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS Z.
�j
Lender's Address P.C.Fee$ N O Permit Fee 2-1101
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, Issuance Fee
M. finical and plumbing construction,and hereby authorize Investigation Fee
re se ati th County to enter upon the above- , Total Fee
e ' n rty f r inspection purposes
Signa re icant or .gent ate SEE REVERSE FOR EXPLANATORY LANGUAGE