HomeMy WebLinkAbout1377 SIMS PL (4)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, Ct a certificate of Workers' Compensation Insurance,
rt
q a�,f�d copSHerW,( ec. 38M, Lab. C.)
Pc!,cy No. Co-5mpony ,-11
11 Certified copy is hereby furnished.
R3 Certified copy is filed with the county building inspec-
tion department. ^�
Dale-'�' ps OI Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars ($I00) 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
(j"I k07, Lic. Class C —S3
Contract o ' A Y0E)�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 em 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 as their
sole compernsolion,or a licensed contractor will do all
other work and the structure is not intended or offered
for sale (Section 7044 B8P 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.
Lender's Address
I certify that I have read this application and state that the
above information is corrncf. 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 vas + unry to enter upon th above-
mrntio pro i pection purposes.
$ n um 1 . phmnt or Agrr+ ore
APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
TF CE8 1 rG 7017lFsl
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
BUILDING
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LOCALITY
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NEARES
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1 SIZE OF
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PROCESSED BY
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NO.
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VALUATION
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DESCRIPTION OF WORK
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Conduits, Conductors,
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Gas System
Anti -Syphon
MECHANICAL
Swimming Pool Heater-
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SEE REVERSE FOR EXPLANATORY LANGUAGE
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