HomeMy Public PortalAbout9854 VAL ST_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self f
insure, or a certificate of Workers'Compensatioir Insurance, APPLICATION FOR COMBINATIM4 SWIMMING POOL PERMIT
or a certified copy thereof(Sec. 380 , Lab.C.) 7BA20B �1
Policy No." /•ooFfipany 1- COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. L�•IY'�(�•ri �
Certified co FOR APPLICANT TO FILL IN BUILDING
copy is filed with the cou bui ng inspec- �f � ADDRESS O
tion department. BUILDING � ` '
_ ADDRESS L LOCALITY
Date)---rr 9y APpli �' 2 p NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY � e' 7 ZIP % C7 a CROSS ST.
COMPENSATION INSURANCE I SIZE OF ASSESSOR
TRACT I h, LOT LOT NO. MAP BOOK S 3 PAGE O� PARCEL
(This section need not be completed if the permit is for one TEL WS; USE ZONE MAP
hundred dollars($100)or less.) OWNER y. . i4 �/_�'I O. a 1 a NO. f 1oZ6
1 certify that in the performance of the work for which this �• SPECI L
. p
permit is issued, I shall not employ any person in any manner ADDRESS -T 14 J/Q-u "1 CONDITIONS
so as to become subject to the Workers'Compensation Laws. t� DISTRICT STATISTICAL CLASS TYPE PROCESSEJBY
CITY ' `L L Ar r ZIP / 7 C� CONST.
Date Applicant ARCHITECT OR TEL CIASS NO/
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NT" Q $ NO. $] C,S pP
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS s L. 0 VALIDATION
with comply with such provisions or this permit shall be TEL•
deemed revoked. CONTRALTO 7-NdNPOOLS NO. $ J1500
LICENSED CONTRACTORS DECLARATIONLIC•
ADDRESS 1- NO.
I hereby affirm that I am licensed under provisions of Chapter 9 - LIC $
(commencing with Section 7000)of Division 3 of the Business CITY CLASS _
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
FINAL -��✓� ►
License Number f C7 Lic. Class SWIMMING POOL L DATE
Contractor Date - SPA ' 7 6 FINAL
SQ. BY IL
❑ I am exempt under Sec. SIZE O
B.&P.C. for this reason ELECTRICAL U
Inc
Date: O
Steel &Conduit Bonding
Signature Conduits, Conductors, Equipment 8
SINGLE FAMILY W
n.
HOME OWNER-BUILDER DECLARATION PLUMBING -; Z
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and P-Trap A :t:T_-
Professions Code): Gas System (-
I, as owner of the property, will do the plumbing and Anti-Syphon �= o=)-
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 is not intended or offered
o
for sale (Section 7044 B&P Code). Swimming Pool Heater t.:y:I a
CONSTRUCTION LENDING AGENCY 3303
�+-�•==
I hereby affirm that there is a construction lending agency for APPLICANT TEL. �} _ T I ENC
the performance of the work for which this permit is issued (PRINT) iHU NO
(Sec. 3097, Civ. C.). , TOTAL 803 - 46
Lender's Name ADDRESS HIECI% Z"
y t
Lender's Address /y ^ t1H,N_
/ .V�
I certify that I have read this application and state that the P.C.Fee$ Permit Fee
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee lel_ s ,� .af �,�y
mechanical and plumbing construction,and hereby authorize Investigation Fee j 1313. -I}I._1 1 2 10 r ,
representatives of th' County to enter upon the above- Total Feeavl M ' j Ah Ir •'1,
mentioned pert i specti n purposes.
Signature of Applicant a Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE