HomeMy Public PortalAbout9842 OLIVE ST_Swimming Pool__ WORKERS_rQLMPENSATION DECLARATION
hereby affirm that I`hose r certificate ns tion Int to self APPLICATION FOR COMBINATION SWIMMING POOL PERPMT
insure, or a certificate of Workers'Compensation Insurance,
or a certified copy there f Se ..38r�000_,aLab. C. 76A20B
,cy0 3195C�� / pill i, S � N L GE876(3/84)
Olicy o. Company 11.� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
BUILDING
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS
tion department. 1' /� ( BUILDINGia- i7 -
Date 23> v•� ��A`� W l`JC ADDRESS ` ) V 1 LOCALITY /
Applicant
CITY f/yV � ZIP NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS SR 31
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT "LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one ( On USE NE, MAP
hundred dollars($100)or less.) OWNER 4 S 1 1/
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 CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCE ED BY
CITY-�ir'Vl L( ZIP CONST.
Dare Applicant ARCHITECT OR TE. Q CLASS NO. /
NOTICE TO APPLICANT: If, after making this Certificate of
ENGINEER ((k [L° Z NO.ab O t L V
Exemption, you should become subject to the Workers' L •-�— VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS Q 1 Y v
with comply with such provisions or this permit shall be TEL. $ �/� VALIDATION
deemed revoked. CONTRACTOR rti P� l NO.�b �y 7 (J(�
LICENSED CONTRACTORS DECLARATIONLIC•
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS g0L1 Tr Sf NO. (9007-- $
(commencing with Section 7000) of Division 3 of the Business LIC.
and Professions Code,and my lij�e nse is in full force and effect. CITY 11'�Q�(/` CLASS 3
v DESCRIPTION OF WORK ❑ FINAL
License Number I 1 Q�I Lic. Class G S3 SWIMMING POOL DATE 0}
jj�� Sc '309 ( SPA a!s3
Contractor � � L��JDare � �� "� SQ.FT. FINAL / A �6 3 9.Q A U
❑ � BY �LLG `
I am exempt under S c. SIZE # 0 0 0 0 211
B.&P.C. for this reason ELECTRICAL 0
Date: o o51,32
w
Steel &Conduit Bonding _ n.
Signature Conduits, Conductors, Equipment 0 0 0 5 1,5 2 5 U)SINGLE FAMILY Z
HOME OWNER-BUILDER DECLARATION PLUMBING ® C 1.23-86
1 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 o 6 3 9 1 A
electrical work. I,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL 0 0 0 0 0 3
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Hearer - 18300
CONSTRUCTION LENDING AGENCY 0 0 1 6 3 G) 0I hereby affirm that there is a construction lending agency for �.- '/ �i
the performance of the work for which this permit is issued
APPLICANT 1�t1�1' )(� NO.377 3&b
PRINT LJ l W
(Sec. 3097, Civ. C.). � 0 1.23-86
Lender's Name ADDRESS 40 G 6H 9/y j�ylr�S��-
Lender's Address P C.Fee$ ( ' Permit Fee I Q
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County C/l
ordinances and State laws relating to building, electrical, Issuance Fee iJ/J(J
mechanical and plumbing construction,and hereby authorize Investigation Fee 7
representatives of this County to enter upon the above- Total Fee I t
me Toned propert for in ection purposes.
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Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE