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Home My Public Portal About4452-4454-4456-4458 TEMPLE CITY BLVD_Swimming Pool__ s _WORKOS' COMPENSATION DECLARATION ,f hereby affirmthat I have a certificate of cement to self . APPLICATION FOR COMBINATION SWIMMING POOL PERMIT list insure ora certificate of Workers Compensation h ensaon Insurance, or a certified copy thereof (Sec 3800 Lab C ) - 76A - CEBT6(9/84) Policy No Compony��fy i COUNTY OF LOS ANGELES BUILDING AND SAFETY �Certified copy is hereby furnished BUILDING T Certified copy is filed with the county building mspec FOR APPLICANT TO FILL IN ADDRESS ip �' 01 hon deportment [TRACT LDINGLAY' DRESS LOCALITY Dat _r Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORK Y ~ ZIP CROSS ST COMPENSATION INSURANCE SIZE OF ASSESSOR LOT LOT NO MAP BOOT( PAGE ' PARCEL (This socHon need not M completed IF the pirmlt Is for ors. TEL USE Z MAPundred dollen (5100)or less ) NO I certify that in the performance of the work for which this . SPECIAL permit a mued, I shall not employ any person In any manner DRESS CONDITIONS so as to become subject to the Workers Compensation Laws DISTRICT STATISTICAL CLASS - TYPE PROLE D Y CITY C ZIP arASS NO CONST Date Applicant ARCHITECT OR // „ TFL — 1/ NOTICE TO APPLICANT If after making this Certificate of ENGINEER /W/ NO 9 VVV Exemption you should become subject to the Workers' - /.�/'L VALUATION - + Compemation provisions of the Labor Code you must forth ADDRESS (/` Ac C O �O / VALIDA N with comply with such provisions or this permit shall be CONTRACTS TEL f deemed revoked LICENSED CONTRACTORS DECLARATIONLIC I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS .2 LNo //9.. S (commencing with Section 7000)of Division 3 of the Business CITY - CLASS`' _ and Professions Code and my license is in full force andeffectDESCRIPTION OF WORK ��'rrr��yyy�tt""" FINAL License Num6e Lic Clain SWIMMING POOL 1 �w ATE �j ► r } (u� -Contractor Dote SPA FIMA U I am exempl un r Sec shy ErTwje t f29a8A 8 B 8P C for thin reason I # e e e 2 1 0 ELECTRICAL Date I e e 6 a 05 W Si nature Steel 8 Conduit Bonding t a g Conduits Conductors Equipment + �e ee6a056 Z SINGLE FAMILY , HOME OWNER BUILDER DECLARATION PLUMBING 0 9 2 4-8 5 1 hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 7031 5 Business and + Professions Code) i P-Trap , Gas System - E:1I as owner of the property will do the plumbing and Ant,Syphon ;129a9 A electrical work I or my employees with wages as their _ , sole compensation,or o licensed contractor will do all MECHANICAL # e e e e 3 other work and the structure is not intended a offered _ - Lt , , - far sole (Section 7044 BSP Code) + Swimming Pool Heater 1 A 1 - 2,3926 CONSTRUCTION LENDING AGENCY L t herebypperformance affirm that there is a construction which t len g agency for APPLICANT `'� /�/` - • - 2,39.265 the ar(armance of the work for which this permit is issued r Y')'sT ► (Sec 3097 Cw c ) - 0 9 2 4 —8 5 Lender s Name ADDRESS Lenders Address Q rm22a-,16 L + P C Fee �6$'S t DS Peit Fee 2 I certify that I have read this application and state that the above mfornghon is correct I agree to comply with all County �otJ V 1 Issaonce Fee ordinances and State jaws relating to building electrical } t mechanical d plumbing construction and hereby outho 'I Investigation Fee representat sof this County to enter upon the above Total Fee J .0 maM o or inspection purposes 9�2 V- S,grwture of App a or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE