HomeMy WebLinkAbout7342AWORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of on t t If cons
a se APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lqb. C.) 76A20B
CE876 (3/84)
Policy No. Company �r 1L_�/1_.L_9h_�Z=_
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
I,a depart ent. BUILDING /
ADDRESS
,Date / Applicant
CERTIFICATE OF EXEMPTION F O WORKERS' CITY
COMPENSATION 11\1 CE TRACT
IThis Faction na0d not be completed if the permit is. for one
undred dollars ($100) or less.) OWNE
I certify that in the performance of the work for which this
permit Is issued, I shall not employ any person in any manner ADDRESS
so as to 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 li ense is in full force and effect.
License Number Lic. Class
Contracto( k36 (( 1 /A Dote
I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
SINGLE FAMILY
HOME OWNER-BUILDJER DECLARATION
I hereby affirm that I am exempt from the Contrattor'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
u electrical work, 1, 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 fqr inspection purposes, _
COUNTY OF LOS ANGELES
FOR APPLICANT TO FILL IN
ZIP
SIZE OF LOT LOT NO.
<:
TEL.
NO.
CITY /--e ZIP
ARCHITECT OR �_-� /���
ENGINEER r�/Gk
NO,
ADDRESS
CONTRACTOR - a
TEL.
NO.
ADDRES I
LIC.
�NO.,�
CITY
(
LIC.
CLASS
DESCRIPTION OF WORK
SWIMMING POOL
SPA
SQ. FL
SIZE
ELECTRICAL
Steel 8 Conduit Bonding
Conduits, Conductors, Equipment
PLUMBING
P-Trap
Gas System
Anti -Syphon
MECHANICAL
Swimming Pool Heater
APPLICANT
TEL.
(PRINT)', 114E -s
NO.
ADDRESS r Q U/_)
P.C. Fee E `� �� �Q Permit Fee
Issuance Fee
Investigation Fee
Total Fee
BUILDING AND SAFETY
1 ADDRESS ,
LOCALITY
NEAREST
CROSS ST.
ASSESSOR
MAP BOOK
USE PNE
�CJ. l
Joao J
MAP
NO.
SPECIAL
CONDITIONS
DISTRICT I STATISTICAL C
`v CLASS NO.
l/� PAGE I PARCEL
/ o .3 �,C.r
ISS TYPE PROCESSED BY
CONST.
VALIDATION
s
FINAL
(►DATE t�
FINAL A 7 J 4. G R
BY Pt. aA �� • • e 2 1
16 • b7,6
U
O C�9 87
"Y
FIE AV D
rm
APR 2 q' 18
L ?GMERIING GEOLOGY
LA CO. DEPT. OF PUBLIC WORKS
Snure of Applicant or Agent Date SEE REVERSE FOR EXPLANATOR`Z LANGUAGE