HomeMy Public PortalAbout9750 VAL ST_Swimming Pool__ WORKERS COMPENSATe
RATION `
1 herebyaffirm that I have a cconsent to self '
unit or o certificate of Work. ahon-Ineurtance . :`APPLICATION- FOR COMBINATION SWIMMING POOL PERMIT
or d p .of(SecC ) 7M%IB
CE 20 pvett
0 ompanCOUNTY OF LOS ANGELES BUILDING,AND SAFETY
Certified copy a herebW
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filed rding ihsp3a/ FOR APPLICANT TO FILL IN app E
BUILDING /"�
ADDRESS LOCALITY (�/4 -
Applrca
CERTIFICATE OF EXEMPERS CITU ZIP CRO55 57
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO ASAP BOOK PAGE PARCEL
(This stolon need tsol M mmplofod IF the permit Is For one TEL USE ZONE MAP
It dollen (f 100)or Int ) OWNER NO NO .200 .3
I certify that in the performance of the work for which this rL SPECIAL
permit is issued I shall not employ any Penton in any manner ADDRESSLessShQ /s CONDITIONS
so as to become subject to the Workers Compensation Laws DISTRICT STATISTICAL CLASS TYPE MCCESSED4IY
CITY ZIP D CLASS _ CONST
Date Applicant E'NGK ER A J
NOTICE TO APPLICANT If after making this Certificate of ENGIFEER a3
Exemption you should become subject to the WorkeriVALUATION
Compensation provisions of the Labor Code you must forth- ADDRESS
with comply with such provisions or this permit shall be TEL $ VALIDATION
deemed revoked ICONTRA
LICENSED CONTRACTORS DECLARATIONLIC IF
I hereby affirm that I am licensed under provisions of Chapter 9 $
(commencing with Section 7000) of Drvmon 3 of the Business CITY LLI h5505;,.R >
and Professions C e and�4yease is in full force nd e t DESCRIPTION OF WORK d
(IFINAL , V
License um Lic Clas SWIMMING POOL DATE — Z z cc
Con Doves SPA NNAL V
❑ SO FT By W
am exempt under Sec 512el 6
/ N
8 8P C for this reason ELECTRICAL _ G
_
Dote
Steel 8 Conduit Bonding
Signature Conduits Conductors Equipment s 4 0 7 8 A
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor s License } 7 C 253
ense �
Law for the following reason (Section 7031 5 Business and P-Trap i e e 1 7 (1,2 5 v
Professions Code) Gas System i
as owner of the property will do the plumbing and Anti-SyphonID 0 9 i 0 -84
electrical work I or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure it not intended or offered
for sale (Section 7044 B&P Code) Swimming P of Heat4 0 7 9 A
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency forese •,• • • 2 1
the performance of the work for which this permit is issued APR
(Sec 3097 Civ C ) �/�• p (PRI 2 • 7921
Lender s Name��, , ADDRE • e • o �7 9 2�1 Z
X01
Lender s Address / 0 9 1 0-84
P C Fee S -� Penna Fee 3. J
I rtif that I have read this application and state that the
m arn rs correct I agree to comply with all County J,.Edmonces and tats relating to budding, elecu¢al Issuance Fee Q,hanical an lu bmg onsiruchon and hereby authonze Invesngatwn Feeese otiv of his C unty to enter upon the above Total Fee ti o rt for action purposes r
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Signmar f Apple nt or AR m e SEE REVERSE FOR EXPLANATORY LANGUAGE