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Home My Public Portal About9432 OLIVE ST_Swimming Pool__ WORKERS'r+UNP,FNSATION DECLARATION ss j hereby a certificate Matte of W aers'Come of consent to self APPLICATION FOR COMBINATION StrWIM PO insure, or a certificate of Workers'Compensation Insurance, MING ®L PERMIT c tifte copy thereof(Sec. 3800, C.) 76420B /Il CE 76(3/84) olicy o. ompany COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING /� / (�oe�tifiepar meis n}filed with the ca b iId' g inspec- BUILDING p ADDRESS I �- / 1 �Ci 'Tr A ADDRESS �y3 © , \✓ LOCALITY �( 0 Date pplicant NEAREST CITY 1 ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF ASSESSOR COMPENSATION INSURANCE TRACT LOT LOT NO. MAP BOOK AGE PARCEL (This section need not be completed if the permit is for one TEL. USE ZONEMAP hundred dollars($100)or less.) OWNER NO. 'I N0. 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 ADDRESS - VC 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 O �� TEL. NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER 405 NO.{p�.Zv ►r ��i111 (� 94 Exemption, you should become subject to the Workers' VALUATION ADDRESS .U U I�d 11J� d t�, LA Compensation provisions of the Labor Code, you."must forth- ,l/� —� VALIDATI N with comply with such provisions or this permit shall be / TEL. $ ',v Vv(' deemed revoked. p P CONTRACTP'1:3 f5[ NO. Q [ LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRES NO.Uajoi $ ` (commencing with Section 7000) of Division 3 of the Business CIS, LIC. and Professions d and my license is in full force and effect. CLASS / �j�- DESCRIPTIO OF WORK License Number [/� i' Lic. Class`S, SWIMMING POOL FINAL �f i"P DATE `.!7j � ® 224:Z3 A �01) [r '�(� SPA Jl►W/�"I FIN # o 0 0 0 `Z 1 O Contra �—L•sate // (� ' S0.FT. � /' p2�YJ /� BY V ❑ I am exempt under Sec. SIZE B.BP.C. for Phis reason r ° ° 6�0 5 ELECTRICAL / 5 W • Date: 0 0,o 6 O Steel 8 Conduit Bonding Signature Z g Conduits, Conductors, Equipment O � O-$J5 fA SINGLE FAMILY Z HOME OWNER-BUILDER DECLARATION PLUMBING ' I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and P-Trap A 2 4 2 4 A Professions Code): Gas System I, as owner of the property, will do the plumbing and Anti-Syphon / # 0 0 0 0 0 3 electrical work. I,or my employees with wages as their sole compensation,or a licensed contractor will do all MECHANICAL other work and the structure is not intended or offered r ° 2 3 9.3 6 l'/// �J, for sale (Section 7044 B&P Code). Swimming Pool Heater CONSTRUCTION LENDING AGENCY ° ° 23936 I hereby affirm that there is a construction lending agency for APPLICANT NLS. O 710-85 the performance of the work for which this permit is issued PRINT 00``''''GG (Sec. 3097, Civ. C ) Lender's NameADDRE v� Lender's Address / 5 P.C.Fee$ �/��V�)�J^ Permit Fee ��L I certify that I have read this application and state that the above information is correct. I agree to comply with all County //J ordinances and State laws relating to building, electrical, Issuance Fee ( V s mecha tid plumbi onstruction,and hereby authorize Investigation Fee rep ntave of hi C unty to enter upon the above- Total Fee menti ro ert for in pection purposes. Signature of Applicant or Ag ate SEE REVERSE FOR EXPLANATORY LANGUAGE