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HomeMy Public PortalAbout9715 RICHMOND WAY_Swimming Pool__ WORKERS'COMPf.NSATIONS DECLARATION hereby affirm that I have a certificate of consent to self :� �� PERMIT insure, or a certificate of Workers"CompensGtion Insurance, APPLICATION 0 Ok,COMBINATION SWIMMI or a certified co y.thereof(-ec., 00, Lab. C.) 76A20B f' f /'q 7. CES76(3/84) Policy No Zw `Company �. ��,.'�- COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. F1 Certified co FOR APPLICANT TO FILL IN BUILDING copy is filed with unty b ' 'ng inspec- ADDRESS tion department: BUILDING 7,L5— l G 1 )� � LOCALITY ADDRESS JJ Date C Applic n CITY e / ZIP CROSS NEAREST. 1 61J CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF ASSESSOR AA_ COMPENSATION INSURANCE TRACE LOT LOT NO. MAP BOOK �(.�� PAGE /% PARCEL ��• �This section need not be completed if the permit Is for one A_ /j+� f l TE USE ZONE MAP undred dollars($100)or less.) OWNER ,�"t/�� °t'�J ` /� N zf- 3 NO. y o� I certify that in the performance of the work for which this / n _ SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS r /� /il//� / CONDITIONS so as to become subject to the Workers'Compensation Laws. CITY Q ZIP DISTRICT STATISTICAL CLASS TYPE PROCESSED BY CONST. Date Applicant ARCHITECT OR TEL. CLASS NO. NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. _?P t & 0 Exemption, you should become subject to the Workers' VALUATION Compensation provisions of the Labor Code, you-must forth- ADDRESS with comply with such provisions or this permit shall be 176 gp/e�/ �GNj��) �.s $ VALIDATION deemed revoked. CONTRACTOR �' P ` / IVc7 / J� LICENSED CONTRACTORS DECLARATION ADDRESf/ C f. C• [.j C�/�ldt � I hereby affirm that I am licensed under provisions of Chapter 9 r NO. $ (commencing with Section 7000)of Division 3 of the BusinessCITY (, AI;e/?i p CLASS and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK ^ FINAL License Number � 2 0/Lic. Class SWIMMING POOL � DATE Confrace 'V I �Lu Date 6^ �`� SPA FINAL a SQ. FT. �y 9 D1 am exempt under Sec. SIZE R sY B.&P.C. for this reason ELECTRICAL Date: C Steel &Conduit Bonding Signature SINGLE FAMILY Conduits, Conductors, Equipment W a CrHOME OWNER-BUILDER DECLARATION PLUMBING ® w Z I hereby affirm that I dm exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and P-Trap Professions Code): Gas System - ' rz 1, as owner of the property, will do the plumbing and Anti-Syphon electrical work. I,ok my employees with wages as their sole compensation,or a licensed contractor will do all MECHANICAL - other work and the structure is not intended or offered i('",'�; for sale(Section 7044 B&P Code). Swimming Pool Heater © _ -. I.- CONSTRUCTION -CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for _ ,� Y';_=E•: APPLICANT / / TEL. 7 (�[�j the performance of the work for which this permit is issued (PRINTLJ4A G}� / NO. I (Sec. 3097, Civ. C.). -r-y'�,: " '''i2-m Lender's Name ADDRESS /SOct All 0® 1,y ` s (�/L �/'�J ;_c s:•.`,. .'�' ,_.. Lender's Address r� 7(� ��/• t7.� Permlt Fee J / I!3=Ei ._r•: I certify that I have read this application and state thatP.C.Fees the ` above information is correct.]agree to comply with all County a� 76" a State laws relating to building, electrical, Issuance Fee investigation Fee - r =!'itis` plumbing construction,and hereby authorize 9 i!I {:I._-i �, ;,r; ,; of thi County to enter upon the above- Total Fee 1 a"e y f inspection purposes. iri ii&l Date L SEE REVERSE FOR EXPLANATORY LANGUAGE