HomeMy Public PortalAbout6431 TEMPLE CITY BLVD_Swimming Pool__ WORKERS COMPENSATION DECLARATION
hereby affirm that I have certificate of aeon Int to APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers
whon kers Compennaurance<e
or 0 ertrfr copy thereof (Sec 3800, Lob C ) 7eAZOB
1y Policy %o company r;VsCYVNhV4 CE 875(11/81)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished FLAn,CA
❑ FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county bu ing impec- ADDRESS QYh
hon de rim nt
Dote �+ Applicant = I I eYY) f LOCALITY 191 L
Is NEAREST
O
CITY ZIP CROSSST G
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF ASSESSOR
COMPENSATION INSURANCE TRACT LOT I LOT NO MAP BOOK PAGE PARCEL
Is section need not be completed N the perms Is for orle
undred dollen($100)or less ) OWNER TEL _9 j � USE ZONEAo
I cern that in the , sYs NO
certify performance of the work for which thin .) r LECIAL
permit is issued shall not employ any person m any manner ADDRESS L >ZM y ONDRgNS
so as to become sublect to the Workers Compensation LowsCITY ZIP DISTRICT STATISTICAL CLASS I TYPE PROCESSED BY
j
Dote Applicant ARCHITECT OR TEL CLASS NO
NOTICE TO APPLICANT If user making this Certificate of ENGINEER NO CONST
Exemption you should become subject to the Workers � � VALUATIONJr
Compensation provisions of the Labor Code you must forth- VALIDATION
with comply with such provisions or this permit shall be CONTRACTOR I r Dv4� t2P NO —74,7/oS / Q� ��
deemed revoked (�
LICENSED CONTRACTORS DECLARATION ADDRESS l/() b� ' Ltjp 3-19
1 hereby affirm that I am licensed under provisions of Chapter 9 S
(commencing with Section 7000) of Division 3 of the Busmess �, .Z A 4 4 19 oZ LIDS 1
?rLd Professions Code and my I come rs in full farceLjL{nd effect DESCRIPTION OF WORK T d
License Number '21
J 1 Lis Closs `" f SWLWWNG POOL J` � DATUE ���� ► V
SPA
s LL7L�
�1Controctor Date r Jr�R FINAL O
❑ FT BY LLLULLL
I am exempt under Sec SIZE
d
B 8P C for this reasonN
ELECTRICAL -777
/x Z
Date ® �
Signature Steel 8 Conduit Bonding
SINGLE FAMILY Conduits Conductors Equipment
HOME OWNER-BUILDER DECLARATION PLUMBING ►
I hereby affirm that I am exempt from the Controctars.License
Law for the following reason (Section 7031 5 Bosiness�nd } p Trap
Professions Code) Gas System is is • • ° 3
❑
I as owner of the property will do the plumbing and Anti Syphon i
electrical work I or my employees with wages as their - 2 ° •16 a.6 3
sale compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered °I• ° 6 &6 3 6
for sale (Section 7044 B&P Code) Swimming Pool Hooter ® 5, 4 $4
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for p APPLICANTp
the performance of the work for which this permit is issued pRINT)Sf A� SO �GP X469' 7L ,
(Sec 3097, Civ C )
r/
Lender s Name ADDRES51d W kK eVk1
Lender s Address T
PC Fee f 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 Iswance Fee
ordinances and State laws relating to building electrical
mechanical plumb. construction and hereby thonze Imomgahon Fee
repre a of unty to enter upon the above Total Fee
m oyer i pection purposes
gnmure of AppLca Agent /D�e SEE REVERSE FOR EXPLANATORY LANGUAGE --1