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Home My WebLink About1641A 1953AI WORKERS' COMPENSATION DECLARATION - - 1 hereby affix thn ka m _ of `ar=e, °se it' APPLICATION FOR COMBINATION SWIMMING POOL PERMIT insure, or a certificate of Workers Compensation Insurance, ora certified copy thereof (Sec 381 Lab G.) 7sA20a No - .� C[878 (3/04) _ Policy ® CertifiedComcopy is herebypfurnurnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec- tion department. _ Date Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for ones? hundred dollars ($100) or less.) " I certify that in the performance of the work for which this.; permit is issued, I shall not employ any person in ony manned so as to become subject to the Workers' Compensation Laws.', f. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become s It t h W k J lec io t e or ers:.; Compensation provisions of the Labor Code, you must forth -` FOR APPLICANT TO FILL IN BUILDING I QEC 3 A - for sale (Section 7044 B&P Code), with comply with such provisions or this permit shall be deemed revoked. 1' CONTRACTO NS �'� TEL NO $ 6.7 .--� f - ADDRESS � - ADDRE 7 LIC �g &UILDMG 7 TEL. 1 hereby affirm that I am licensed under provisions of Chapter 9 ' ' {Sec. 3097, Civ. C. ). - Lender's Name $ NO. ADDRESS i� �A )/1 LIC. LOCALITY , and Professions Code, and my liven is in full force and effect 'i r`f r3 CITY a+{ FINA NEAREST DESCRIPTION OF WORK Foe License Number e Lic. Class( SWIMMING POOL /T DATE p \ ! '(,g... 6 \ DATE 1 �" O CROs ST. Contractor �Jf�; SPA r ting to electrical, me, icaI a d plumbi co ruction, and hereby authorize -" Investigation Fee an ce Fee SIZE OF �Fl le ® I am exempt under Sec. ASSESSOR Total Fee FINAL By TRACT LOT MAP BOOK - AGE PARCEL OWNER s"1 ,L4J�( Vi3EAf NOL. 1Z USE ZONE MAP NO. rI, ADDRESS P I C r^' SPECIAL Steel & Conduit Bonding / ? 1 SINGLE FAMILY HOME OWNER -BUILDER DECLARATION Conduits, Conductors, Equipment CONDITIONS S {� I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business PLUMBING - DISTRICT STATISTICAL CLASS TYPE PROCESSED BY CITY - ZIP 1-7 � 10 CLASS NO. CONST. electrical work. I, or my employees with wages as their ARCHITECT OR EL. ENGINEER sole compensation, or a licensed contractor will do all MECHANICAL J lec io t e or ers:.; Compensation provisions of the Labor Code, you must forth -` ADDRESS VALUATION I QEC 3 A - for sale (Section 7044 B&P Code), with comply with such provisions or this permit shall be deemed revoked. 1' CONTRACTO NS �'� TEL NO $ 6.7 .--� f - VALIDATIO$'1 LICENSED CONTRACTORS DECLARATION ADDRE 7 LIC �g i hereby affirm that there is a construction lending agency for the performance of the work for whit this permit is issued APPLICANT TEL. 1 hereby affirm that I am licensed under provisions of Chapter 9 ' ' {Sec. 3097, Civ. C. ). - Lender's Name $ NO. - I ommencing with Section 7000) of Division 3 of the Business !- �A )/1 LIC. ADDRESS - and Professions Code, and my liven is in full force and effect 'i r`f r3 r /VI/ CLAss FINA s fid, A- - DESCRIPTION OF WORK Foe License Number e Lic. Class( SWIMMING POOL - - DATE p \ ! '(,g... 6 \ DATE 1 �" O ► Contractor �Jf�; SPA r ting to electrical, me, icaI a d plumbi co ruction, and hereby authorize -" Investigation Fee an ce Fee .® _e 2 le ® I am exempt under Sec. SIZE Total Fee FINAL By - , . 28� 8 8P C. for this reason of Ap t or Agenl Date �'' 3 y 5 LS• - ELECTRICAL `.��{� , --Date:. rI, Signature Steel & Conduit Bonding SINGLE FAMILY HOME OWNER -BUILDER DECLARATION Conduits, Conductors, Equipment S {� I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business PLUMBING - - - and Professions Code): P -Trap - 1, as owner of the property, will do the plumbing and Gas System Anti -Syphon -- - - electrical work. I, or my employees with wages as their sole compensation, or a licensed contractor will do all MECHANICAL other work and the structure is not intended or offered -' - I QEC 3 A - for sale (Section 7044 B&P Code), Swimming Pool Heater 'i} z_ - CONSTRUCTION LENDING AGENCY i hereby affirm that there is a construction lending agency for the performance of the work for whit this permit is issued APPLICANT TEL. c - {Sec. 3097, Civ. C. ). - Lender's Name (PRINT) NO. S ,( ADDRESS Lender's Address—_-- (,�./- P.C. Fee $�+ d J Permit - _ 1 certify that I have read this pplicotion and state that the �i Foe \ - - above information is correct. I agree to comply with all County i" ordinances and State laws building, is Issu - r ting to electrical, me, icaI a d plumbi co ruction, and hereby authorize -" Investigation Fee an ce Fee - re 1. .tan Co y to enter upon the above - Total Fee m ❑t, red erty f r i ction purposes. of Ap t or Agenl Date �'' SEE REVERSE FOR EXPLANATORY LANGUAGE - - Cl (o o w° ° n °F°OAF .gym o — �`"•'3mm�.�3m D tz ° (= 0 o a o< 3 (p 0 o N c^❑ w o v, m o n o z c y H N O m a- CD O ID ti w 6 O K O O_ 0 0 O O O p❑ na�m�`0 11 ID yooZ�moo�m°°��Qf,p rn oID ` 3 3 ^0 3 m 3 m° 01-0 (D3 0� 0 0 0 �.`°-0 afl COQ 3 � Ooa� 'gym .m Ivo oHm3� o� X CD 3° °< N ,0 �."� O ° �• (0 O O Q O N (D a• r (p O C n0 O O C o— n 63 ID o Y' a o s o> > a m ° F 0 3 m ° Q o 3 0 ° 0 F o ° 0 n o o 0' w ry N s° 'C 0 o m A m E° z vo'Q.o 04; ❑ F Ti m o 0 a o o 3° fl o m° m £. m o °, o i ti o 3 -rn 00 o m o roo oY o,.Z. _� 303 !� 1 °<N 0 o v M 0 0 3< 0 ° .K p — n O n , O C o n 0_ M H S O n fl 0 77 'n a c.,,t1 0 0` a. a °- s -o o = 3 ° -. 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