HomeMy Public PortalAbout10569 OLIVE ST_Swimming Pool__ •"'"`VV(3Wt RS'COMPENSATION DECLARATION
insure,
3 cortifica I have Workers'
Come of consent to Self APPLICATION FOR COMBI ATION SWIMMING POOL PERMIT
insure, or a cgrtificate of Workers'Compensation Insurance, •
or a certified cop thereof(Sec. 3800, Lab. .) 76A20B
CE-875(11/81)
Policy No. "� Company v!// COUNTY OF LOS,ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. _
BUILDING �•
0 Certified copy!.,filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS
tion department. BUILDINGr
ADDRESS �� LOCALITY
Date, ApplicantNEAREST
CITY ��p [ ZIP_ CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF ASSESSOR
COMPENSATION INSURANCE TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one- cTEL. USE ZONE MAP
hundred dollars($100)or less.) OWNER ti tc .g NO. '��7 NO...
I certify that in the performance of the work for which this ,�ys / SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS ��/� A; �'( CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT- STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CLASS NO. CONST.
Date Applicant ARCHITECT OR // TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER r`• t'f NO. �Ga
Exemption, you should become subject to the Workers' Q �,,,/ t
ADDRESS 2 �. �����h VALUATION
Compensation provisions of The Labor Code, you-must forth- � � VALIDATION
witli comply with such provisions or this permit shall be j .N .. $ t
deemed revoked. CONTRACTOR °� ®�/
LICENSED CONTRACTORS DECLARATION _61 LIC'
ADDRESS V �i
NO.
I hereby affirm that I am licensed under provisions of Chapter 9 LIC /' $
(commencing with Section 7000)of Division 3 of the Business CITY rte/ CLAS
and Professions Code�and my license is in full forcee and effect. DESCRIPTION OF WORK.
FINAL
1.1141' E
nse Number �`�o��+ Lic. Class.VSWIMMING POOL DATE ad
adContractor. auk Date SPA FIN U
SQ.FT.
M I am`exempt under Sec.
SIZE 0 B
H
ELECTRICAL
B.&P.C.for this reason Z
Date:
Si nature Steel &Conduit Bonding
9 Conduits, Conductors, Equipment.'
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING ► zS 3 4 7,8 A
1-hereby affirm that I am exempt from the Contractor's License
Law for the•following reason. (Section 7031.5, Business and P-Trap o2 1
Professions Code): - Gas System
El
I, as owner of the property, will do the plumbing and Anti-Syphon 2 a o 4 0 1 7
electrical work. I,or my employees with wages as their o,o o / _
sole compensation,or a licensed contractor will do all MECHANICAL `( 1 a
other work and the structure isnot intended or offered7 0 — '
for sale (Section 7044 B&P Code). Swimming Pool Heater L J `
CONSTRUCTION.LENDING AGENCY + 3 G•7 9 A
I hereby affirm that there is a construction lending agency for APPLICANT ,p N /� TEL `
the performance of the work for which this permit is issued (PRINT) rAD d. ��� NO. 3'y' ' o o/o 0 0 3
(Sec. 3097, Civ. C.). ,/� , 2 -'1'4 5 Q.
Lender's Name ADDRESS S �/ 00 C�1�6 # JOW&-f +
Lender's Address 'L \
P.C.Fee$ % !L,41 Permit Fee �®iV
1 certify.that I have read this application and state that the 0'7.0 8— 8„
above information is correct. I agree to comply with all County Issuance Fee 0,
JV
ordinances and State laws relating to building, electrical,
mechanical and plum 'ng truction,and hereby authorize Investigation Fee
representatives ofounty to enter upon the above- Total-Fee
per inspection purposes.
n>,1W
Signature of Applica r Agent Date. SEE REVERSE FOR EXPLANATORY LANGUAGE
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