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HomeMy Public PortalAbout9822 RICHMOND WAY_Swimming Pool__ WORKERS'COMPENSATION DECLARATION L I hereby affirm that I have certificate of consent to self APPLICATION FOR COAAMNATION SMMAMING POOL PERMIT insure, or a certificate of Workers'Compensat,'prt JnsurCnce, j I I or a certified copy thereof_(Se, 800, Lab. C.) l7snz0s jlJI /�' / + n J CE878(3/841 Policy N 7✓Coat dny_ f- �r �!�/" _ COUNTY OF LOS ANGELES � BUILDING AND SAFETY ❑ Certi ied copy is hereby furnished. QBUILDING ��- Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS d9 tion department. BUILDING !.9 1 j X"lc fal./4 f11�i �� . �,� �.,, ADDRESS s + LOCALITY Dater _Applicar4f!� - +/ NEAREST CITY C/t//'�E t� F ! ZIP �al '�s v/ CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF ASSESSOR COMPENSATION INSURANCE TRACT LOT LOT NO. MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one !/ TEL. USE ZONE MAP hundred dollars($100)or less.) OWNER / %/y.,��l, NO. J � ';� 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 CONDITIONS so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS E OCESSED BY CITY ZIP r CLASS NO. �. Date Applicant ARCHITECT OR TEL. h,Dif �{/ NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CC9> 1. I 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 be1 I TEL.O. ;,�- $ 7 t t c,r!� VALIDATION deemed revoked. CONTRACTQItl �, ,lig) N / 6 f L t'` LICENSED CONTRACTORS DECLARATION .11C. ADDRESS?4_� Ii _ . Ls+ ^ I hereby affirm that 1 am licensed under provisions of Chapter 9 - - - _ $ (commencing with Section 7000)of Division 3 of the Business LIC. �� CITY f, .. CLASS_ and Professions Codeiand my license is in full force and effect. DESCRIPTION OF WORK � FINAL License Number - 7s _ Z- Lic. Class •� SWIMMING POOL - ���'��"� //y� 'f), DATE Contractds "/ I Ef'� Date -f' - SPA ���� D FINAL } SO. FT. 7 BY / LGG(.I/�� a 1 am exempt under Sec. SIZE /i C B.&P.C. for this reason ELECTRICAL Date: C Steel &Conduit Bonding H Signature Conduits, Conductors, Equipment V W SINGLE FAMILY EL HOME OWNER-BUILDER DECLARATION PLUMBING Z I hereby affirm that I am exempt from the Contractor's License _ Law for the following redson (Section 7031.5, Business and e4 Professions Code): P-Trap a Gas System / °,E I, as owner of the property, will do the plumbing and Anti-Syphon 765.45 electrical work. 1,or my employees with wages as their sole compensation,or a licensed contractor will do all MECHANICAL 2 ITEN other work and the structure is not intended or offered for sale (Section 7044 B&P Code). Swimming Pool Heater © TOTAL 944 4 o 5-6 CONSTRUCTION LENDING AGENCY t= I hereby affirm that there is a construction lending agency for _ CHECK 944°"�h APPLICANTTp -•— the performance of the work for which this permit is issued (PRINT ° (Sec. 3097, Civ. C.). L• '� `' CHANGE 010, Lender's Name ADDRESS ��� �t: AM 10'.37 Lender's Address P.C. Fee$ �y! 9 Permit Fee 7d* 70 0000- q D�1 7/15/96 G' /• �/ I certify that I have read this application and state that the ` • 432 y above information is correct. I agree to comply with all County fi 7S ordinances and State laws relating to building, electrical, Issuance Fee �Y mechanical and plumbing construction,and hereby authorize Investigation Fee s representatives of this County to enter upon the above- Total Fee 5 , mentioned property-oar inspection purposes. ,y 'tignature of,1ApPF.0cnt or Age'' nt — Date SEE REVERSE FOR EXPLANATORY LANGUAGE