HomeMy Public PortalAbout9515 PENTLAND ST_Swimming Pool__ .., WORKERS COMPENSATIbN DECLARATION
hereby affirm that I have a certificate of consent to ,elf
nsAPPLICATION. FOR COMBINATION SWIMMING POOL PERMIT
iure or o certificate
Insurance of Workers Compensation nsurance
or a certified copy thereof (Sec 3800 Lab C ) 7WOB I - I . ••
` �s'� T-}����E ^.� ceeTe Il
Pohcy d`�f mpany�fymLLL N , deaCOUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy Is hereby furnished
. FOR APPLICANT TO FILL IN, BUILDING
�ertified copy is filed with the county budding mspec- ADDRESS
Iron department + s BUILDING
ADDRESS /VD LOCALITY
Date —Applicant
NEAREST
_ CROSS ST _
I
CERTIFICATE OF"EXEMPTION FROM WORKERS CITY Sej]lyIZE OF ' ZIP ASSESSOR
COMPENSATION INSURANCE • TRACT LOT LOT NO MAP BOOK - PAGE PARCEL
(This section need not be completed If the permit is for on• 'TEL U ONE _ MAP -
hundred dollars ($100)or less ) • '. OWNER NO,r{,Ev NO '
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 STATISTICAL CLASS, �+ TYPE PROCESSED BY
CITY - ZIP 6C V tT CONST
Date Applicant ARCHITECT OR TEL - l a CLASS NO r 4
21 NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO Jt •Y'
Exemption, you should become subject to the Workers ` ' 'VALUATION it
Compensation provisions of the Labor Code .you must forth- ADDRESS
with comply with such provisions or this permit shall be _ CONTRACTORL/ NOL $ ��r r VALIDATION
deemed revoked _
LICENSED CONTRACTORS DECLARATION s, _ IC
ADDRE D
17
I hereby affirm that I am'hwnsed under provisions of Chapter 9 LIC /l�-� $ -
(commencing with Section 7000) of Division 3 of the Business CITY CL455 C.T) 7
and Professions Code and my license is in full force and effect - 1 O 1 5 A
DESCRIPTION OF WORK
/� /J�� _ FINAL F n
License Numlble/Ir�''U7ld� LIc Class(-ZLL1 SWIMMING POOL II v�I' DATE - # • • * 21-
a'
2 1-
zContracto'&4W Date !�Q- SPA 9 - u FINAL ,c' I I • 101.6 4 -, r
BY
❑ I am exempt under Sec SO •i• 1 01.646 oI
B 8P C for this reason ELECTRICAL 0 2 Tr 8 8 i LY
Date •' j - - -- FI
Steel 8 Conduit Bonding U
Signature Conduits Conductors Equipment - _ Lill
SINGLE FAMILY r f ' t N
HOME OWNER BUILDER DECLARATION PLUMBING II�✓._I�/' ;@,l O 1.6
CA ' Z
hereby affirm that I ons exempt from the ontractor s License '
` I�J J
Low for the follow)ng reason (Sectionn a Co • •�•,e • 3
Professions Code) P Trap , ti _
Gas System , . . _ _ _ . `'I i351176'
as owner of the property will do Ihe'plumbing and Anti-Syphon
electrical work I or my employees with wages as their ,. - • or 3 5,1.7 6 3
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure Is not intended or offered - _ `I O2 7t 8 8
for sale (Section 7044 B8P Code) Swimmmg Pool Heater ¢ '
CONSTRUCTION LENDING AGENCY _
I hereby affirm that there is o construction lending agency for APPLICANT t TEL -t
the performance of the work for which this permit is Issued . (PRINT) _ p
(Sec 3097 C,Y,C loop
Lender s Name ADDRE 0• - '
Lenders Address - A 3 2 _
PC Fee S ( Perms Fec
e
I certify that I have rood this application and state that the /
above information a correct I agree to comply with all County -
ordinances and Slate jaws relating to budding electrical Issuance Fee iV V y
mechanical and plumbing construction and hereby authorize Invesiiganan Fee -
representatives of this County to enter upon the above Total Fee
m ho4ec� for an purposes i
n
grAp icon,or Agent Data SEE REVERSE FOR EXPLANATORY LANGUAGE