HomeMy Public PortalAbout9813 RICHMOND WAY_Swimming Pool__ WOR IZ S'COMPENSATION DECLARATPN
I hereby_affirm111 at I have. a'certificate of consent to.self
insure., r.a certifAeWs.of Workers'Compensation Insurance, APPLICATION FOR COMBINA `SWI MING POOL PERMIT
or a ceff+fied rsy thereof p.5- 3B�0, Lab. C.) 76A20BjMi
ZLil ; CE876(3/84)
Policy 31 Company �l�Ifod e—. COUNTY OF LOS ANGELES BUILDING AND SAFETY "
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS, 164014
tion department. BUILDING
ADDRESS I3 /C.J'* � � ./1 ' LOCALITY L-
Date1-1:97 Applicant is NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY �L.� J ZiP 17vO CROSS ST. 40WA N, UJ6v-
COMPENSATION INSURANCE SIZE OF ASSESSOR p�
TRACT LOT LOT NO. MAP BOOK �p f PAGE DO--LO PARCEL Ofl
(This section need not be completed if the permit is for one TEL. USE ZONE MAP
hundred dollars($100)or less.) OWNER NO. NO.
I certify that in the performance of the work for which this �9�JJ ,An p� SPECIAL
permit is issued, I shall not employ any person in any manner. ADDRESS 0/-3/�IG�Jlvlv !/ (�( CONDITIONS
so as to become subject to the Workers'Compensation Laws. p DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY // Z ZIP 1 700 CONST.
Date Applicant ARCHITECT OR TEL. CLASS NO /
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' ADDRESS VALUATION
Compensation provisions of the Labor Code, you.must forth- / _ h _ TELpv VALIDATION
with comply with such provisions or this permit shall be CONTRACTOR �/ , („ NOZ�� $ ���� �
deemed revoked. c )e�� n
LICENSED CONTRACTORS DECLARATION ADDRESS // C•IfY ,Cs
I hereby affirm that I am licensed under provisions of Chapter 9 /��_/y, LIC r_ $
(commencing with Section 7000)of Division 3 of the Business CITY64A16 4l6 / CLASS C05-3
and Professions Code,
and]my license is in full force and effect. DESCRIPTION OF WORK
License Number 1015 0? Lic. Class ✓�� SWIMMING POOi. o7a FINAL ►
1 �j 7 f �] DATE '
Contractor-�I`�15 !t)Date G G��� / SPA FINAL }
SQ.FT. � BY C
I am exempt under Sec. SIZE C:
B.BP.C. for this reason ELECTRICAL Q. / ��
Date: �
6 C
Steel 8 Conduit Bonding a�Q 3 C.,
Signature Conduits, Conductors, Equipment J o
SINGLE FAMILY a
cr
HOME OWNER-BUILDER DECLARATION PLUMBING ACCTog Z
z
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Trap 3303 784.79
Professions Code): ' Gas System 1 ITEMS
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I,or my employees with wages as their TOTAL 784.. 79
sole compensation,or a licensed contractor will do all MECHANICAL CHECK 7i�ta7
other work and the structure is not intended or offered
for sale (Section 7044 BBP Code). Swimming Pool Heater CHANCE ■OBJ
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT ,�
the performance of the work for which'this permit is issued (PRINT 7__85Zz� 00 6862
612/96
(Sec. 3097, Civ. C.). dJ 1862 1 AM10:20
Lender's Name ADDRESS&&& gF, -e /rr� 5'
Lender's Address 4/
P.C.Fee$ Permit Fee
I certify that I have read this application and state that the
above information is correct. I agree to comply.with all County �o
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical and plumbing construction,and hereby authorize Investigation Fee
representatives of this County to enter upon the above- Total Fee o�
mentioned proper" r inspection purposes.
r
gnature of pplicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE