HomeMy Public PortalAbout9836 VAL ST_Swimming Pool__ ✓ /SII
WORKERS COMPENSAjION DECs.ARATION ,I
hereby affirm that I have a certificate of consent to ,elf APPLICATION FOR COMBINATION SWIMMING POOL PERMIT lul
insure, or a certificate of kepensation Insurance
or a certdi copy thereof (Sec 3800 Lab C ) 7M2M
C , �� CEBT813/8<I
Policy NotJt Company ,_ A8 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Cern sed copy is hereby furnished
FOR APPLICANT TO FILL IN 'ADDDNG CIA V'SE
�Cendsed copy a filed with the co ry bud nspec- ADDRESS
ho d po ment BUILDING
ADDRESS ry LOCALITY
Da Applicantlm NEAREST
CE IFICATE OF EXEMF11 ROM WORKERS CITY v ZIP CROSS S7
COMPENSATION RANCE SIZE OF ASSESSOR
TRACE LOT LOT NO MAP BOOK PAGE PARCEL
(This section need not be completed N the perms Is for oee FEL USEE MAP
hundred dollars($100)or lees) OWNER I•IO NO
I certify that in the performance of the work fee which this �I SPECIAL
permit is issued I shall not employ any person in any manner ADDRESSNJ
CONDITICS
so as to become subject to the Workers Compensation Laws - DISTRICT STATISTICAL CUSS TYPE D BY
CITY ZIP ��-/ C,LASS I CON
S 177
Date Applicant ARCHITECT TFL OY
NOTICE TO APPLICANT If after making this Certificate of ENGINEER
Exemption you should become subject to the Workers ADDRESS ` sLy �J VALUATION
Compensation provisions of the Labor Code you must forth VALMATZIN
with comply with such provisions or this permit shall be CONTRACT TEL $
deemed revoked
LICENSED CONTRACTORS DECLARATION �� S LIC a
1 hereby affirm that I am licensed under provisions of Chapter 9 A ppIK�--` LIC
U�
(commencing with Section 7000) of Division 3 of the Business sLxa CLASS �Q
and Professions Code�and my license is in full force and effect DESCRIPTION OF WORK
License Numbes,_ Ls< Clo SWIMMING Lp FINA6— SS ► }
Conlro<I paM' � �A FINA R
sIZ Pr U Sy
Ions exempt under Sec264&9A
a O
B BP C for this reason ELECTRICAL # s • • e 21
Date W
Steel 8 Conduit Bondsgg I • • 9 Cl 3 6 a
Signature Conduits ConductorsE pment z
SNGLE FAMILY • • - 9Q365
Z
I
HOM WNNGLE LDERDECLARATION PLUMBING
I hereby affum the am exempt from the Contractor s License , 0 210-87
Law for the fol lowing reason (Section 7031 5 Business and p_Trop
Professions Code) Gas System 2 6 4 9.O A
I as owner of the property will do the plumbing and Ants Syphon # 3
electrical work 1, or my employees with wages as their s
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered 1 - 3'1426
for sale (Section 7044 B&P Code) Swimming Pool Heater
CONSTRUCTION LENDING AGENCY •,• 314,2 6 5
I hereby affirm that there is a construction lending agency for APPLICANT TEL - 0 2 1 0`87
the performance of the work for which this permit is issued (PRIM) NO
(Sec 3097 Cry C )
Lender s Name ADDRESS Poo
Lender s Address 3,
PC fees 1 ✓ Permit Fee
above
that I have read this application
gree to non and store that the � ^
above mformanon n correct I agree to comply with all County U
Issuance Fee
ordinances and State laws relating to budding electrical ,
mechanical and plumbing construction and hereby authorize Invesngmsan Fee /
representatives o hss Countyto enter u on t above Total Fee 6
m tion(xd city w in cit purpos r
if
stuns of AppLmm or Agent a SEE REVERSE FOR EXPLANATORY LANGUAGE