HomeMy Public PortalAbout10224 RANDWICK DR_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
Ireby,affirm thpt I have a certificate of consent to self r
insure, or a certifigate of Workers' Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or dcertified copy there (Sec. 3800, L b. C.) 76A20B u
CE876(3/84) '
Po(tcy No.IZ?M Company COUNTY �!r F LOS-ANGELES 1 BUILDING AND SAFETY
�. Certified copy is hereby furnished.
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FOR APPLICANT TO FILL IN BUILDING Certified copy is filed with the county building inspec- ADDRESS do7a
. tion de rtment. 11 BUILDING
IAS ADDRESS LOCALITY G!�
Date IwqzApplicant trv' NEAREST z
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY ZIP CROSS ST. .j
COMPENSATION INSURANCE TRACT SIZE OF LOT LOT NO. MAP BMAP 13OO DDOR "p� PAGEV�S PARCEL
(Thi`s section need not be completed if the per t'is For one TEL. USE ZONE MAP
hundred dollars(5100)or less.) OWNER NO. NO,
I citify that in the performance of f ark for which this SPECIAL
permit is issued, I shall not emplo y person in any manner ADDRESS CONDITIONS
so as to become subject to t orkers'Compensation Laws. /^ DISTRICT{ STATISTICAL CLASS TYPE PROCESSED BY
CITY V_ ZIP r CONST. C
Date Applicant ARCHITECT OR L. CLASS TT
bqL
NOTICE TO LICANT: If, after making this Certificate of ENGINEER AS, O. D
Exerp you should become subject to the Workers' VALUATION
C pensation provisions of the Labor Code, you.must forth- ADDRESS TEL- .��j(( �Q I-� VALIDATION
wit.licomply with such provisions or this permit shall be CONTRALTO ` NO. s �v �v
detained revoked.
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LICENSED CONTRACTORS DECLARATIONLIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS LNO. 1 1 ;
(comipencing.with Section 7000)of Division 3 of the Business CITY CLASS
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
7 FINAL
License Number Lic. Cla SWIMMING POOL c%'�— /, �/ DATE
L "� DatekhzSPA ' FINALto }
Contrpctor SOEFT. 0 BY C
'I am exempt under Sec. r C
.B.&P.C. for this reason ELECTRICAL a
Date: C
Steel&Conduit Bonding L
Signature Conduits, Conductors, Equipment
SINGLE FAI�IL Cr
HOME OWNE�R-BBpER DECLARATION PLUMBING 23 Z
I hereby affirm that from the Contractor's LicenseLaw for the folloeason (Section 7031.5, Business and P-Trop ACCT."
Professions Gas System126. 1
47
I,as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I,or my employees with wages as their 1
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered ACCT.4
for sale (Section 7044 B&P Code). Swimming Pool Heater 03��6
CONSTRUCTION LENDING AGENCY �S 7�sL�
1 hereby affirm that there is a construction lending agency for APPLICA A 1 1 1,, TEL. 7 A V l ITM
the performance of the work for which this permit is issued (PRI.NT) r{�(' r� NO. 15 ,
(Sec. 3097, civ. C.). TOTAL 365-09
Lender's Name NL ADDRESS C�/ 365-09
�41+.
Lender's Address // T/ Q L• e00
P.C.Fee$ (p• 0 Permit Fee ���.J
I certify that I have read this application and state that the
above:information is correct. I agree to comply with all County a ; 7�
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical and plumbing const ction,and hereby authorize Investigation Feem ` �1 1t UK
representatives of this Co to enter upon the above- Total Fee d (o 1 AM 9j*-15
mentioned property for i io purposes.
14 Z
nature of pplica or Agent let SEE REVERSE FOR EXPLANATORY LANGUAGE
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