HomeMy WebLinkAbout8876Ar
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No.o-S-516 Cnmpony e_ l.2.
Certified copy is hereby furnished.
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 one
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, t shall not employ any person in any manner
so as so become subject to the Workers' Compensation Laws.
Date 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 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 3!R01aT0 Lic. Class -C::5
Contractor Sc Q (0-- Date
1 am exempt under Sec.
B.&P.C. for this reason
Signature
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that t am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Cade):
I, as owner of the property, will do the plumbing and
electrical work. I, or my employees with wages as 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 for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
-Lender's Address
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,
mechanical and plumbing construction, and hereby authorize
representatives of this County to enter upon the above -
mentioned property for inspection purposes.
.Tignature of Applicant or Agent Dale
APPLICATIONFOR COMBINATIONSWIMMING IT
76A208
CE878 {3/84)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL 1N
DING 1
BUILRESS
BUILDING ADDRESS .71xif a n c r e-e-k
LOCALITY
CITY IL rip
NEAREST
CROSS ST.
= a _ SITE OF
r�
ASSESSOR
,) TRACT _ -3 LOT
L07 NO.
MAP BOOK
PAGE
PARCEL
OWNER
TEL
NO.
USE ZONE
4
' , i[CONDITIONS
MAP
NO. i ()
ADDRESS m
SPECIAL
f��
DIS ICT STATISTICAL CLASS TYPE
PROCESSED BY
CITY (&=" ZIP
CONST.
( CLASS NO.
ARCH CT OR f"1 TEL
ENGINEER
VALUATION
VALIDATION
..3
z887.6A
# ®• • ° 1
ADDRESS GG Men.
TEL.
CONTRACTOR NO.
LIC_
ADDRESS �� C, Q (1e e_ NO. 32_�Q_'50-
�� c ass [
CITY
FINAL
1 6 s5653
DESCRIPTION OF WORK
�J
SWIMMING POOL
DAT£
® 6 & 5
SPA
C'Y
FINAL
0 6 � Jr 8 7
SO. FT. '�/�
BY
.SIZE l/c'
� y
ELECTRICAL
Steel & Conduit Bonding
Conduits, Conductors, Equipment
����
PLUMBING
P-Trap
Gas System
Anti -Syphon
u
MECHANICAL
Swimming Pool Heater
APPLICANT TEL.
{PRINT}
NO.
RECEIVED
ADDRESS
j _..
� U$�,; p l r UOLOGY
LA GO, DEP3. Ua; UESCIC WORKS
P.C. Fee $5 s�
Permit Fee
ssuance Fee
hnvesti anon Fee
9
Tatar Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
L
J