HomeMy Public PortalAbout9520 PENTLAND ST_Swimming Pool__ WORKERS COMPENSATION DECLARATION �' ✓ -
.by affirm that I have a certificate of consent to self
ins a ar a certificate of Workers Compensation InsuranceAPPLICATION FOR COMBINATION-SWIMMING POOL PERMIT
or a certified copy thereof (Sec 3000 Lob C ) 76A20B
tCE 875 If 1/Bl)
Policy No Company - I� COUNTY OF LOS ANGELES BUILDING AND SAFETY ^
f/1/m/-zlu�ll Certified copy is hereby furnished I
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Certified copy is filed with the county building inspec I FOR APPLICANT TO FILL IN BUILDINGADDRESS
tion deportment I BUILDING CC
Date Applicant 1 ADDRESS LOCALITY Q E
CITY ZIP NEAREST /1 I
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST C1.0
- 17� SIZE OF ��--pp I ASSESSOR i '
TRACT LOT r7v �d No
MAP BOOK/ PAGE PARCEL
COMPENSATION INSURANCE
(This section need not 6a completed d the perms a for one
hundred dollars ($100)or less ) r OWNER /y/ Lj ` TEl d _ U$E_Z�IJE FSP
ZI certify that in the performance of the work for which this ` CIALpermit is issued shall not employ any person in any manner i ADDRESS ONDITIONS
//syQs to become sub je 1 to the W kers Compensation Laws CIN _,�yf ZIP d DISTRICT STATISTICAL CLASS TYPE
NO PROCESSED BY
Uate `� ' pplicant I RCHITECT OR - TEL - C��
NOTICE TO APPLICA T If, after makAg this Certificate of ENGINEER N'O
Exemption you should become subject to the Workers VALUATION
Compensation provisions of the Labor Cade you must forth- ADDRESS
with comply with such provisions or this permit shall be TEL $
VALIDATION
deemed revoked CONTRACTOR - NO b
i LICENSED CONTRACTORS DECLARATION LIC •�
ADDRESS NO
I hereby affirm that lam licensed under provisions of Chapter 9 $
a
(commencing with Section 7000) of Division 3 of the,Busmes,s CIT - LIC LIC •i Y
and Professions Code and my license is in full force and effect DESCRIPTION OF WORK r
License Number Lic Class /� y FINAL O
SWIMMING POOL Lv4' ��t�K� / DATE G ( i 9 4 5 6 A v
p _ ,/ 7 ® o
Contractor Date SPA ' 1 �I (� O`p FINAL oto'• ° 2 1
ri
I am exempt under Sec + SO
SIZEN 1 So —ih �- D BY / ! 2'° ° 6 2 0 0
911.
B 8P C for this reason ELECTRICAL "'f—�'_r I O.Q� '°T° ° 6 2 0 N
E J 0
Date =
Steel 8 Conduit Boris ing •' 03 0'6-8 4
Signature
I- SINGLE FAMILY CondConductors Equipment '
� uits
HOME OWNER BUILDER DECLARATION PLUMBING_
I hereby off irm that I am exempt from the Contractor Is License
Law for the following reason (Section 7031 5 Business and pTrop
Professions Code) i Gas System
I� I, as owner of the property will do the plumbing and Anti Syphon '
LSU electrical work I or my employees with wages as their 9 4 5 7 A -
sole compensahci a licensed contractor will do all MECHANICAL _
other work and the structure is not intended or offered _
for sole (Section 7044 B&P Code) Swimming Pool Heater •-'-'
CONSTRUCTION LENDING AGENCY 2 - 22Q50
1 hereby affirm that there is a construction lending agency for i
the performance of the work for which Ihis permit is issued APF; IPIi NTS �,��� _ ryp 9 GS��. ° ° 2 2(1J 0 c=i
(Sec 3097 C,v C ) Of0
0306-84
Lender s Name ADDRESS oZ
Lender s Address i
I certify that I have read this application and state that the P C Fee f —^ Permit Fee
above mformalion is correct I agree to comply with all County _ _
ordinances and State jaws relating to budding electrical Issuance fee t di7
mechanical and plumbing construction and hereby authorize Invenigotion Fee
representatives of this County to enter upon the above- Toto[Fee
mentioned property for inspection purposes
�� , d
Signature of Applicant or Agent D.J. - SEE REVERSE FOR EXPLANATORY LANGUAGE
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