HomeMy WebLinkAbout0 WORKERS'COMPENSATION DECLARATION
hereby affirm that I have r certificate of tion Int to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure,or a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec.3600,Lab.C.) 76A20B
+"� '1 1 i:, 'Y CE67613184)
Policy No. / company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
copy y g• P FOR APPLICANT TO FILL IN BuILowG a
Certified co is ailed with the count building inspec. ADDRESS
tion depoomept.:< BUILDING
_ ADDRESS - - LOCALITY
Date.' r Applicant _ NEAREST '—
r -
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY ZIP CROSS ST.
OF ASSESSOR
COMPENSATION INSURANCE TRACT`�' LOT:- - LOT NO. ( MAP BOOK PAGE PARCEL
(This ed of nomad not be less.) cod If the permit is for ons TEL. USE ZONE MAP
hundred dollar(5100)or I�fF.) OWNER - - NO. - -' ptp \,� -�,+�•�� I .s- --i—;"
_ I certify that in the performance of the work for which this SPECIAL
permit is issued,I sholl not employ any person in any manner ADDRESS CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT I STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CONST.
CLASS NO.,
Dale Applicant � ARCHITECT OR _ TEL. ..�i- I I
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER - NO. -� 11. •-"{' '
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code,you must forth-. ADDRESS VALIDATION
with comply with such provisions or this permit shall be TEL. S
deemed revoked. CONTRACTOR .NO. '
LICENSED CONTRACTORS DECLARATION LIC•
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
LIC S
(commencing with Section 7000)of Division 3 of the Business
and Professions Code,and my license is in full force and effect. CITY CLASS r
DESCRIPTION Of WORK D_
FINAL A
License Number - Lic.Class - SWIMMING POOL DATE `�3 , f-'���' U
:: I'.' .1: LiJ
FlNA I,p I� J
Contractor Date SPA , •'
SQ. f ... _ BY 1r♦ ,(r°;�'y.(§f' Li
0 1 am exempt under Sec. -
B.8P.C_for this reason ELECTRICAL *.as"' •e��..�I r j�l 'r'.'t` D.^
Date: B �:i,1,;'- :�•
g Steel 8 Conduit Bonding O
Signature Conduits,Conductors,Equipment n'
SINGLE FAMILY { .} W
HOME OWNER-BUILDER DECLARATION PLUMBING Ld
hereby affirm that I am exempt from the Contractor's License
Law for the following reason(Section 7031.5, Business and P Trap
Professions Code): - -
Gas System
ElI,as owner of the property,will do the plumbing and Anti-Syphon
electrical work.I,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL
otherwork and the structure is not intended or offered
for sole(Section 7044 B8P Code). Swimming Pool Heater Q
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for r^
APPLICANT I TEL. r•o t..'�' b .
-the performance of the work for which this permit is issued (PRIMP) NO. S rl.:
(Sec.3097,Civ.C.).
(,.,,•�;.1. v(_
tender's Nome ADDRESS
tender's Address W"' / L.�'y�•;;Gi c)
P.C.Fee S "`" I t Permit Fee
I certify that I have read this application and state that the
obove information is correct.I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical and plumbing construction,and hereby authorize Investigation Fee r .
representatives-of.this County to enter upon the above- Total Fee ..
mentioned proper,{,for,inspection purposes./
S,gnoture of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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