HomeMy Public PortalAbout9465 PENTLAND ST_Swimming Pool__ WORKERS COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent tC self
insure or a certificate of Worke�srrs Compensation Insurance , c APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or\/aj,�e�r/b�fte�d Lcc.opy thereof (SeQWs lab C ) 7oppg
Po ^�f �mpllonlly q els(nlet) COUNTY OF LOS ANGELES - BUILDING'AND SAFETY ,
IF
❑ ,Certified copy is hereby furnished
BUILDING
�/Cerhfi fled with th cairn uildin in'sPec FOR APPLICANT TO FILL IN ADDRESS ' 7 �V
—/rhon Apar ent BUILDING , ` �
ADDRESS�x0.� P TLAJ L� LOCALITY L� C..' c
Dat Applicant
CITY 7 NEAREST
ZIP CROSS ST _
CERTIFICATE OF COMPENSATION
I N FROM WORKERS f� SZ OF ASSESSOR
COMPENSATION INSURANCE TRACT / LOT LOT NO MAP BOOK PAG PARCEL
(Thu section'.wd not be completed If the permit is for ono TEL ,,��`` USE ZONE MAP
hundred dollars ($100) or less ) OWNER /T) O.-W5-e_ NO a� 7v , NO
1 certify that in the performance of the work for which this �/ / - SPECIAL
permit is issued I shall not employ any person in any manner ADDRE ( / J0 CONDITIONS
so as to become subject to the Workers Compensation Laws , DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CLASS NO / CONST
Dole—Applicant ARCHITECT O //'' TEL - OryQ_
NOTICE TO APPLICANT If after making this Cerehcote.of ENGINEER ��pp�� M/ NO SzU1V
Exemption' you should become subject to the Workers ADDRESS/,),O'/'Sot7�r'� VALUATION
Compensation provisions of the Labor Code you must forth \ VALIDATION
with comply with such provisions or this permit sholl be TEL - 6 I / `(l
deemed revoked CONTRACTOR/_ /� N v v
LICENSED CONTRACTORS DECLARATION ADDRESS�Ilo//LJ,EI Z(_J LIC
I hereby affirm that I om licensed u er provisions of Chapter 9 LIC $
(Commencing with Section 7000) Drvuion 3 of the Business
Y
and Professions C and my Lc se is in full force and effect CITY CLASS - d
n ccj DESCRIPTION OF WORK _ FINAL "7 y� O
License Number L,c CIaE .� SWIMMING POOL ®® pA—`+f/• d ►
_ /
Conlro �\Dore �3 SPA ' FINAL i O
50 FT By V
I am exempt under Sec SIZE 1jLJ ,/ A,
B 8P C for this reason ELECTRICAL v � z
I�f 0�O '
/1 Z
Steel 8 Conduit Bonding 8,7,'7 A Bonding ,- r
Signature Date Conduits Conductors Equipment r r
SINGLE FAMILY _ � - $ e 10,;r� It
HOME OWNER BUILDER DECLARATION PLUMBING _ =r� • • • 7 3 6 4 E
,I hereby affirm that I am exempt from the Contractor s License '
Law for the following reason (Section 7031 5 Business and ip Trop r 0331 —8 3
Professions Code) _ Gas System _
I as owner of the property will do the plumbing and Anti Syphon ;20 8 7 8 A
electrical work I or my employees with wages as their
sole compensohon,or a licensed contractor will do all MECHANICAL # • • • •�• 3
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code) Swimming Pool Heater 2'-'2 5 a 0,0
CONSTRUCTION LENDING AGENCY - `. - 25a005
I hereby affirm that there is a construction lending agency for AFRICAN -
the performance of the work for which this permit is issued (PRINT TE r
(Sec 3097 C,v C )
Lender s Nome�Y'�
/��r ADDRE
Lender s Address _
P C Fee S Permit Fee
' I certify that I have rite this application and state that the '
abov#an
car ct I agree to comply with all County _ - -
ordinle I ws relating to budding electrical Isseance Fee
methb 9 construction and hereby author zitrepres County to enter upon the above Total Feementi inspection purpoont or A em (/✓','�/to. t SEE REVERSE FOR EXPLANATORY LANGUAGE