HomeMy Public PortalAbout9308 OLIVE ST_Swimming Pool__ WORKERS'C�`�PENSP,'�ION DECLARATION FOR
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hereby affirm that I have a certificate of consent to self {�®It COMBINATION I®Il® ���IIPI/r,'�@ll P®®� PERM, ��
insure, or a certificate of Workers' pensation Insurance, APPLICATION LI
or a certified copy thereof (Sec. 3 0 a 76A20B
t CE876(3,84)
P
o. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
rtified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDR Nrtified copy is filed with the county building inspec- ADDRESS
de ar BUILDING l
ADDRESS ' LOCALITY 1
Datom J&
e % plicont _ NEAREST
CIT ,e,(, 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 oneT L USE ONE MAP
hundred dollars($100)or less.) OWNS NO.
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 ADDRES I CONDITIONS
so as ec me subject to the Workers' mpensat'on Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY T ZIP /- �& COfj}57•
Dat pplicant ARCHITECT OR TEL. J Uo CLASS NO. 1(((JJJf.'�O`'i/
NOTICE TO APPLICANT: If, after making th Certificate of
ENGINEER NO. �
Exemption, you should become subject to the Workers' ADDRESS VALUATION
Compensation provisions of the Labor Code, you must forth- \�� VALID TION
with comply with such provisions or this permit shall be TEL_
deemed revoked. CONTRACT NIt
LICENSED CONTRACTORS DECLARATION IC.
t.l.A]
I hereby affirm that 1 am licensed under provisions of Chapter 9 ADDRE $
LIC. " 7
(commencing with Section 7000)of Division 3 of the Business CITY s e___ I CLAS
and Professions a li a se is in full force and effect. DESCRIPTION OF WORK l
C 7 FINAL +�
License Number Cla= SWIMMING POOL a � ^9 DATE a
`� SPA d FIN L U
Contrac 4 ate SQ FT.
❑ 1 am exempt under Sec. SIZE e 4 5 6 9 A
0
B.&P.C. for this reason ELECTRICAL # o 0 0 0 2 1 I-
U
Date: I o o 8 U.7 9 a
Steel 8 Conduit Bonding N
SignatureConduits, Conductors, Equipment o 0 0 8/( ]Q 6Z
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING 05.01 —8o
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 tF�e property, will do the plumbing and Anti-Syphon P_4 5 7.0 A
electrical work. I,or my employees with wages as their
sole com��ensation,or a licensed contractor will do all MECHANICAL # 0 0 0 0 0 3
other workZand the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater ( 0 2 C! 5.::0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT/' TEL. 0 0
the performance of the work for which this permit is issued (PRINT 2 S 5.
(Sec. 3097, Civ. C.). VitaO 5 0 1 - 36
Lender's Name ADDRE 7r� r /J
Lender's Address P,C Fee 8 1? Permit Fee eZ J L(/�
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County Issuance Fee (!t J
ordinances and State laws relating to building, electrical,
mechanical and plumbing construction,and hereby authorize Investigation Fee �Q
epresentatives of this County to enter upon the above- Total Fee (J
nt n roperty inspection purposes.
Signature of Applican or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE