HomeMy Public PortalAbout8603 WORTHINGTON DR - Swimming Pool - 1991-04-19 1 WORKERS'COMPENSATION DECLARATION
I here�Lby,offirm that I )cove a certificate of consent to self �p
insure, or a certificatevf Workers'Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or a �tfsi d t.,*r' f(Sec. 3800, Lab. C.) 76A20B
✓'�v f � CE876(3/84)
Policy N ompany l� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. BUILDING
�j
Certified copy is filed with th ounty building inspec- FOR APPLICANT TO FILL IN ADDRESS
c3 -�,�
tion department. BUILDING d p �b AJ �1�•_�—H
q- ! ADDRESS (}
Date `�` Applicant LOCALITY
NEAREST
CERTIFICATE OF EXEMP �N FROM WORKERS' CITY ZIP CROSS ST.
COMPENSATI INSURANCE SIZE OF ASSESSOR /
TRACT LOT LOT NO. MAP BOOK! JVAGE ARCEL
(This section need not be completed if the permit is for one �C ��^ TEL. USE ZONE MAP
hundred dollars($100)or less.) OWNER 1 � J NO. NO.
I certify that in the performance of the work for which this7� tSPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS C, �� u-r �„ i 72'N CONDITIONS
so as to become subject to the Workers'Compensation Laws. -� DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY / ZIP CONST.
Date Applicant ARCHITECT OR TEL. �QO CLASS NO�
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' ADDRESS VALUATION /
Compensation provisions of the Labor Code, you must forth- ,L cr / VALIDATION
with comply with such provisions or this permit shall be CONTRACTOR G- -��T ��S NO.�G -�YS�O s
deemed revoked. g
LICENSED CONTRACTORS DECLARATION ��j LIC. �/
ADDRESSS p � �. 7_,W1,10 S,',NO. J 0 C -Z
I hereby affirm that I am licensed under provisions of Chapter 9 LIC $ }�
(commencing with Section 7000)of Division 3 of the Business CITY 5��c CLASS C-^••5—,3
and Professions Co/de,and my license is in full force and effect. DESCRIPTION OF WORK
License Number r r'���� Lic. Class -✓� FINAL Olt,
-�� 'moiSWIMMING POOL ppTd
Contracto�,4t,Y ® Date —` SPA FIN s • W
EJSIZEFT. BY izf::•• ns
I am exempt under Sec.
JL���_
: Lf� f IC•:.✓
B.BP.C. for this reason ELECTRICAL
ate: - W
Signature _ - Steel 8 Conduit Bonding � �' .Jt N
Conduits, Conductors, Equipment .��//
I GLE FAMILY ---- -- ::Z
E OWNER-BUILDER DECLARATION
I hereby aff' thPLUMBING
at I am exempt from the Contractor's License LIE
Law for the following reason (Section 7031.5, Business and Poo
P-Trap E_I;eiL � mC-
Professions Code): Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon r�° + c
electrical work. I,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL CHANGE of t1
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY _l_i:•fz)- I�i�f ++l'is 1,i
I hereby affirm that there is a construction lending agency for APPLICANT f i 14 ;i? t
the performance of the work for which this permit is issued (PRINT) �C3� �u:-6(Ci¢ TEL.g1177 �.L,.30
(Sec. 3097, Civ. C.). �j / / ► v
Lender's Name ADDRESS
Lender's Address
P.C.Fee$ Aler Permit Fee
1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County 3,&V
ordinances and State laws relating to building, electrical, Issuance Fee
mechar ical and plumbing construction,and hereby authorize Investigation Fee ASe,
�/�taivesenter upon the above- Total Fee e purposes.
.ure of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE