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HomeMy Public PortalAbout9309 PENTLAND ST_Swimming Pool__ v h x- WORKERS COMPENSATION DECLAQA;ION hereby affirm that I have a certificate of on int to .elf i APPLICA,TIONFOR COMBINATION SWIMMING POOL PERMIT insure or a certificate of Workers Compensation Insurance r or a certified copy thereof (Sec 3800 Lab C I 6A20B q _ i Policy Noq7? ompanyOF 171111/81,' COUNTY OF LOS ANGELES ( BUILDING AND SAFETY ❑ Certified copy is hereby furnished Certified co is filed with the county bui din inspec FOR APPLICANT TO FILL IN BUILDING t PY ty g pe ADDRESS CY r tion department BUILDING - ADDRESSO LOCALITY' Dote Applicant NEAREST - CERTIFICATE OF EXEMPTION FROM WORKERS CITYAs ZIP CRO55 ST COMPENSATION INSURANCE SIZE F ASSESSOR i TRACT LOT LOT NO MAP BOOK PAGE PARCEL y(This sxhon need not be completed If the permit is for one TELUSE ZONE MAP �- hundred dollars($TDO) or less ) OWNER NO.Zg4 yS NO ^©•- - I certify that in the performance of the work for which this - -" SPECIAL permit is issued I shall not employ any person rn'any manner ADDRESS CONDITIONS so as to become subject to the Workers Compensation Laws DISTRICT, STATISTICAL CLASSTYPE . PROCESSED BY i CITY ZIP CLASS NO CONST ^+Data Applicant ENGNI EER NL r o1 9 fid/ NOTICE TO APPLICANT If, after making this Certificate of Exemption, you should become subject to the Workers -' VALUATION , Compensation provisions of,the Labor Code you must forth- ADDRESS lit with comply with such provisions or this permit shall be TEL ' f O VALIDATION deemed revoked CONTRACTOR NO (�� LICENSED CONTRACTORS DECLARATION LIC ADDRE NO 1419 I hereby affirm that I am licensed under provisions of Chapter 9 f "(commencing with Section 7000) of Division 3 of the Business 'n LIC _ Y and Professions Code and my It is in full force and effect Cl - -�f�.�,e,� /J CLASS 6 p DESCRIPTION O6 WORK FINAL � O License Number �/J9yya Ln: Glass C°S �, SWIMMING POOL ' IU�x--'I e ��I /�/J Q GATE � �D SPA j4e—ot/" J� " 9 FIN y r Coniractorl�L.N'�s� Data SQ FT ir BY V O We am exempt under Sec SIZE a ZS ,7 1,8'A d N B 8P C for this reason ELECTRICAL - '# e.• • 21 Z Date Steel 8 Conduit Bonding SINGLE FAMILY - _ s 0 tet2 s i7 9, 2 1 `2 Signature Conduits Conductors Equipment B i a4 7 9.2 1 x _ HOME OWNER BUILDER DECLARATION PLUMBING 4,-$4 1 hereby affirm that I am exempt from the Contractor s License c`hP1111. `--. _ Law for the,following reason (Seon 7031 5 Business and p Trap Professions Code) Gas System r ElI as'owner of the property will do the plumbing and Ant, Syphon _ _• electrical work I or my employees with wages as their ' t sale compensation,or a licensed contractor will do all MECHANICAL , other work and the structure is not intended or offered ` I for sole (Section 7044 B&P Code) - Swimming Pool Heater CONSTRUCTION LENDING AGENCY hereby affirm that there is a construction lending agency for APPLICANT TEL the performance of the work-for which this permit is issued - (PRINT) NO polo(Sec 3097 Civ C ) - - 0 7 1, 9"A Lender s Nome ADDRESS - - - j # e • • • • 3 '2'a'2 7'6 7 6 Lender s'Address r 12,�•�7 6� P C Fee 5 Parmn Fee' - • a I certify that I have read this application and state that the � , above information is correct 1 agree to comply with all County - - - Issuance Fee 0 4 2;4'-8 4 ordinances and State laws relating to building electrical mechanical and plumbing construction and hereby authorize Investigation Fee I - I representatives of this County;to enter upon, the above Totol Fee r mentioned property for i spec I, purposes - - �' Signature of/ phi .nt or Agent - Doie SEE REVERSE FOR EXPLANATORY LANGUAGE' '