HomeMy Public PortalAbout9891 WENDON ST_Swimming Pool__ 7 h Wffirn
'(_c' IPENSATION DECLARATION
insure,
cericaI faave r certificate of consent to Self APPLICATION FOR COMBINATION SWI POOL PERMIT
insure,ar a certificate of Workers'Compensation Insurance, 0 SWIMMING
or a certified copy thereof(Sec. 3800, L b. C.
76A20B
Polic 0A &Com / /j f CE876(3/84)
y No.�Y�� Pan r � COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING f
Certified copy is filed with the county building inspec- ADDRESS
tion department. BUILDING p�
ADDRESS / ��� LOCALITY
Date Applicant `
CITY �f Gr ZIP NEAREST
CERTIFICATE OF EXEMPTION FRO ORKERS' / CROSS S
f/
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 Q TEL. L� USE ZONE MOP
hundred dollars($100)or less.) OWNER
I certify that in the performance of the work for which this' SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS g 9� 71/ u �J�' CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICTSTATISTICAL CLASS TYPE PROCESSED BY
CITY � ZIP (,' CQIQST. V
Date Applicant ARCHITECT OR EL. /�x CLASS NO vj]/
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' VALUATION v
Compensation provisions of the Labor Code, you-must forth- ADDRESS
/ J TEL.
deemed revoked. ,) VALIDATION
with comply with such provisions or this permit shall be CONTRACTOR /// QQ/ NO. `f Z s � odd
LICENSED CONTRACTORS DECLARATION LIC.
d
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.LIC $
(commencing with Section 7000) of Division 3 of the Business CITY J % CLASS
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
' r+ t&F
NAL ,
License Number 0 Lic. Class �"7 SWIMMING POOL � (IAT '� }
Contractor S Date — SPA "-�❑ SQ.FT.I am exempt under Sec. SIZE (�
B.BP.C. for this reason ELECTRICAL O
Date: W
Signature �Y�C�7. Steel 8 Conduit Bonding e N
Conduits, Conductors, Equipment �
SINGL AMIL
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and P-Trap ® 2 9 2 a 8 n
Professions Code): 4J
Gas System # • • • • o
I, as owner of the property, will do the plumbing and Anti.-Syphon ( - 1061 3
electrical work. I,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL RR r Z
other work and the structure is not intended or offered U 4 8
for sale (Section 7044 B$P Code). Swimming Pool Heater Q
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANTTEL. c 9 2 a 9 A
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.). (PRINT) NO. # • o • • '3
Lender's Name ADDRESS �. • - 56690
Lender's Address t / /1 s/0 3 • • • 5(1,9 0 S
P.C.Fee$ J / V• Permit Fee l i c�
1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County //��
ordinances and State laws relating to building, electrical, Issuance Fee `0 c 5 o LL 0 1 —8 8
mechanical and plumbing construction,and hereby authorize Investigation Fee
representatives of this County to enter upon the above- Total Fee
men property for inspection purposes.
Signature of Applicant gwfr Date I SEE REVERSE FOR EXPLANATORY LANGUAGE