HomeMy Public PortalAbout9669 OLIVE ST_Swimming Pool__ WOKERS'COMPENSATION DECLARATION O
reby attirrr) that I havecertificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insuSure, or.a certificate of Workers' Compensation Insurance,
or a e t'fie c y th �re ( . 3800, Lab. C.) 20-0018 DPW 3/87
76A206
onC � (CE876) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
❑ certified copy is hereby furnished. BUILDING � �;
❑ Certified copy is filed with the co my building inspec- FOR APPLICANT TO FILL IN ADDRESS �(CaL7 , Gy
tion department. BUILDING
,71�, ADDRESS LOCALITY
Date 1 _Applicant / NEAREST
CERTIFICATE OF EXEMPTION FROM RKER CITY `�( ZIP CROSS ST.
COMPENSATION IN URA CE SIZE OF ASSESSOR
TRACT LOT LOT NO. _� MAP BOOK PAGE PARCEL
(This section need not be completed if th if is For one �7 TEL �J�- USE E MAP
hundred dollars($100)or less.) OWNER G__ NO� 72CX<)� NO. /
I certify that in the performance of the work for which this I SPECIAL
permit is issued, I shall not employ any person in any manner ADDRE CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE P ED BY
CITY ZIP CONST.
,rte CLASS NO.
Date Applicant ARC CT TEL-; V '7_per
ENGINEER = NO. OO ✓
NOTICE TO APPLICANT: If, after making this Certificate of �KI
,
Exemption, you should become subject to the Workers' ADDRESS (} 1► 1 VALUATION
Compensation provisions of the Labor Code, you must forth- II'���--'^^`��� VALIDATION
with comply with such provisions or this permit shall be CONTRACT - ` NO. $
deemed revoked.
LICENSED CONTRACTORS DECLARATION ADDRESS NaC_<A- N LIC.
$
I hereby affirm that I am licensed under provisions of Chapter 9 LIC.
(commencing with Section 7000)of Division 3 of the Business CITY CLASS }
a
FINA
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK �
License Numbe Lic. Class_ SWIMMING POOL DATEL
V
X
�At •_`+ SPA FIN 0
Contractoro [ T_Date SQ FT. V
❑ I am exempt under Sec. SIZE
W
D_
B.&P.C. for this reason ELECTRICAL (' � /�jL '� i6e�..t � Z
Date: I(-
Steel &Conduit Bonding
Signature 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. 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 for
sale (Section 7044 B&P Code). Swimming Pool Heater 1 4 I~
CONSTRUCTION LENDING AGENCY ' �.
I hereby affirm that there is a construction lending agency for APPLICA TEL
the performance of the work for which this permit is issued (PRINT) N _
(Sec. 3097, Civ. C.
Lender's Nome kip l ADDR s_ w
Lender's Address P.C. Fee$ Permit Fee
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County D
Issuance Fee
ordinances and State laws relating to building, electrical,
mechanical and plumbing construction,and hereby authorize Investigation Fee
representatives f this County to enter upon the above- Total FeeC,2-10-
_7
J
m tione r pe y for inspection purposes.
40-n
Si nature A Applicant or g t Date SEE REVERSE FOR EXPLANATORY LANGUAGE