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HomeMy Public PortalAbout9830 WENDON ST_Swimming Pool__ J i WORKERS'COMPENSATION DECLARATION I herebyaffirm that 1 have a certificate of consent to self p APPLICATION FOR COMBINATION SWIMMING POOL PERMIT insure, or a certificate of Workers'Com engafion Insurance, o a0vyc,6 fled copy the eof(Sec. 3800, Lab. C.) 76A2os0C p y � � CE876)(3%84)o iCom an � j COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. r APPLICANT TO FILL IN BUILDING AVO.Certified copy is filed FOR APPv with the county building inspec- I ADDRESS Fi tion department. BUILDING ADDRI'SSLOCALITY DateApplic I NEAREST CITY ZI CROSS ST.. . CERTIFICATE OF'EXEMPTION FROM WORKERS' .I COMPENSATION INSURANCE SIZE OF ASSESSOR TRACT LOT LOT NO. MAP BOOK PAGE PARCEL (This section need not be completed If the,permit Is for one 7E USE ZONE MAP / �+ hundred dollars.($100)or less.) OWNER N I NO. I certify that in the performance of the work for which thisI SPECIAL permit is issued,I shall not employ any person in any manner ADDRESS �f CONDITIONS so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE P SSED BY CITY z10-71 CONST. 21 Ac I Date Applicant ARCHITECT OR TEL. Og CLASS NO3)'.. NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. Q _ddd5a Exemption, you should become subject to the Workers' ADDRESS VALUATION 3307 101.53 Compensation provisions of the. Labor Code,.youi must forth- - VA. D T,fQ with comply with such provisions or this permit shall be 7E $ deemed revoked. CONTRALTO NO ` _ 'LICENSED CONTRACTORS DECLARATION ADDRESS �, UPJ LIC NO.( �Z TO I AL 1111.53 1 herebyaffirm that I am licensed under provisions of Chapter 9 $ CHECK (commncing with Section 7000)of Divion 3 of the Business LIC. 2 4t�G\rt� i[)1.5? CITY CLASStJ iJ t� and Professions Code,and my license is in full force and effect. DESCRIPTION OF ORK I. 4rI�i�IV'E - .00 /d�� FINAL License Num//l!b��e��r �pD��� Lic. Class(G SWIMMING POOL DATE �yttl,ri Ikf�nd 9 f �Jtfy1: rLd#f�1'� 7 Date ! Q SPA j FINAL VI.FV0-0001 1 3 relc; Confracto SQ. BY M41 1 AM 8QJe I am. exempt under Sec. SIZE 117 B.BP.C. for this reasonELECTRICAL f, Date: ! Signature �. Steel S.Conduit Bonding ConddiTs, Conductors, Equipment 3 SINGLE FAMILY At`T,Y _ HOME OWNER-BUILDER DECLARATION PLUMBING I hereby affirm that I am exempt from the Contractor's License I ` ® Q� ��e � Law for the following reason (Section 7031.5, Business and i p-Trap Professions Code): , Gas System I ITEMS E] I, as owner of the property, will do the plumbing and Anti-Syphon TOTAL 354 26 electrical work. I,or my employees with wages as their ! +.r m sole compensation,or a licensed contractor will do all MECHANICAL oCK ther other work and the structure is not intended or offered for sale (Section 7044 B&P Code). ( Swimming Pool Heater ©� GFIAitil E .CIE CONSTRUCTION LENDING AGENCY { (' I hereby affirm that there is a construction lending agency for APPOCANT TEL �-t�•t�y�y the performance of the work for which'this permit is issued (fRIN7) O, 0000-0001 1/ 3/90 (Sec. 3097, Civ, C.). t ® 7969 1 AM 811 36 Lender's NameADDRESS r hui. , Lender's Address P.C.Fee E Permit Fee 2T I certify that I have read this application"and state that the above information is correct. I agree to comply with all County p ordinances and State laws relating to building, electrical, Issuance Fee `_ mechanical and plumbing construction,and hereby authorize Investigation Fee represenfati s of this County to enter upon the above- Total Fe - mentione-LiDrp rty for inspection purposes. ,,z ' Ignatur of ppit.rit or Agent Date. I, SEE REVERSE FOR EXPLANATORY LANGUAGE