HomeMy WebLinkAbout6172A 7377A (18)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
ins" re, of_a certificate of Workers' Compensation Insurance,
orbclGTtifieCr copy thereof (Sec. 3800, Lob. C.)
Policy Pfo. f Company
Certifie:,icopy is hereby furnished.
9-Certiffed copy is filed with the county building inspec- tion. department.
Date4aAPplicantT / CIOC
CERTIFICATE OF EXEMPTION FROM ORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit isfor 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 mannersoastobecomesubjecttotheWorkers' Compensation Laws.
Dote 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-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that t am licensed under provisions ofChapter 9
commencing with Section 7000) of Division 3 of the BusinessandProfessionsCode, and my license is in full force and effect.
License Number 67-32-21-- Lic. Class 4-1-f 3
Contractors e-+r.Ci s-C'e5i-T' Date ' e
I am exempt under Sec.
B.&P.C. for this reason
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
1 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, ormy employees with wagesas their
sole compensation, or a licensed contractor will do all
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency fortheperformanceoftheworkforwhichthispermitisissued
Sec. 3097, Civ. C.).
Lender's Name
Lender's
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical,
mechoni al and plumbing construction, and hereby authorize
repres taLives of
thiP—
ty to enter upon the above -
i ned property foction purposes. ,
SgnaNre of Ap i<ant or Agenl Date
76A20B APPLICATION- FOR -COMBINATION SWIMMING POOL PERMIT
CE -875 (11/81)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDINGADDRESS 1 0 30 S l o7 r, n! /'J,
BUILDING—
D,
UILDING,//i
ADDRESS 7.-3 —5X17- r> 1—J, LOCALITY j r.,.t
CITY / /'kp.! dam+ ZIP NEARESTCROSSST. 6+Sl r.f
t SIZE OF ASSESSOR
TRACT -jY- LOT LOT NO. MAP BOOK I PAGE PARCEL
OWNER W'e /7y'/— TELNO. C 5/ USE ZONE OP
SPECIAL
CONDITIONSlADDRESS -e /f ,. /T[j c• rst
a DISTRICT STATISTICAL CLA55 TYPE
CITY { ZIP
IS Je NO CONST.
K7D BY
ARCHITECTOR TEL.VJENGINEER " NO.
ADDRESS %y kwe-1,, Dr t P4 -s VALUATION
s !YD VALIDATIONTEL3
CONTRACTORCvN ,T NO.
FINAL
cb17.2A
4 • • • • 21
I
UC. J r ADDRESS'2/_SZ1 NO.
LIC,
CITY O 4N7o.J CLAS- j
DESCRIPTION OF WORK
SWIMMING POOL v N / r L— DATE
fr _
r''• r.,
fit --•'TJ,
I • . 7J I
SPA
SO. Fl.
1 (/IL_I FINAL
BY o • F S'! c=i
SIZE
5 — 8 a"
ELECTRICAL
Steel &Conduit Bonding EN Conduits, Conductors, Equipment
PLUMBING
Gas System
Anti -Syphon 4 e • • • • 3
MECHANICAL 1.22550
Swimming Pool Heater y
I rl 22S-510E
O 1.02-85APPLICANTTEL
PRINT) NO.
ADDRESS
V4"•'
P.C. Fee E Permit Fee
Issuance Fee `
Invesfigaiion Fee
Tocol Fee r
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