HomeMy WebLinkAbout1377 SIMS PL (2)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, Ct a certificate of
Workers' Compensation Insurance,
q a�,f�d copSHerW,( ec. 38000Lab. C.)
icl
Pc!,cy No. Co-5mpony ,-41
11 Certified copy is hereby furnished.
R3 Certified copy is filed with the county building inspec-
tion department. ^�
DaleT ��' Pi�I Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars (SI00) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
saps
Io become subject to fire Workers' Compensation Lows.
Dale Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
wi!h comply with such provisions or this permit sholl be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License Number k& L07, Lic. Class C —53
Contract o ' A YOlh�5 Date Z
I am exempt under Sec.
B.BP.C. for this reason
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5. Business and
Professions Code):
I, as owner of the property, will do the plumbing and
electrical work. 1, or my employees with wages cis their
sole compnnsolion,or a licensed contractor will do all
other work and the structure is not intended or offered
for sale (Section 7044 BSP Code).
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Nam. Ci�n+L�nwJ
Lender's Address
I certify that I have read this application and state that the
above information is corrnct. I agree to con+ply with all County
ordinances an S-ale laws relating to building, electrical,
mechenical d p nstrucfion, and hereby authorize
represent ves + unry to enter upon th above-
mrntio pro i pecfion purposes.
$ n um 1 . phmnt or Agrr+ ore
APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
TF CE8 1 r6 701J lest
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
BUILDING
ADDRESS I MS
I n
LR
LOCALITY
s
CITY {
ZIP -n II� S
NEARES
CRO55 STT.
1 SIZE OF
TRACT LOT
s� , I
LOT No.. / T
AP BOOK PAGE
MAP
PARCEL
TSO•p
OWNER ,y ,
I� NOay 'SI
USEZOhE
ADDRESS �] 151 test-
SPECIAL
CO
CITY D 14s Wb •auE
ZIP 111 VS
DISTRICT
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STATISTICAL CLASS
CLASS No
CLASS
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S ST
PROCESSED BY
ARCHITECT ORENGINEER
NO.
•
ADDRESS
VALUATION
$ a D� VALIDATION
No
CONTRALTO RI.A.tt f C
S
,
FINA
3 (1 f
ADDRfSSIC{.,SObMC ?a SUr NO. IBSI
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CITY j�tt7dQAs ki'�LK CLASS C-S3
DESCRIPTION OF WORK
®
SWIMMING POOL
DATE ►
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SPA
FINAL
( • • 5 p• 8 I
SO. FT. .1
By
SIZE
J7 ✓ /L+}f`I^p �G+�^/�jJ�Q�
. o a 5 i. F, I
O ,rl i) I — FI F�
ELECTRICAL
Steel& Conduit Bonding
Conduits, Conductors,
Equipment
PLUMBING
,
P-Troo
Gas System
Anti -Syphon
MECHANICAL
Swimming Pool Heater-
.
I. n n
•
( • I FI EI O O
AIPLICANT I TEL.
PaO1S
(PRINT)
NO
••I�fGO
St A,
ADDRESS
P.C. Fen S
Permit Fee
\w
hsuonce Fee V
Invesr[).+ion Frr.
To+al Fee IOr
W
l `9,9 , 00
SEE REVERSE FOR EXPLANATORY LANGUAGE
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