HomeMy WebLinkAbout1316A 2203A WORI ��.111QN DECIARATION� ' �. �+�
1 hereby of(ir� �c,a ce:�ificotP of�o�se����o,�e�F �APPUCATION FOR COMBINATION SWIMMING POOL PERMIT u
insv�e,or v n kers'Com ensotion Ins�ran a`, "�
or a cei�i'e c .i�5ec.3800, ab.C.) � ��7gA20e � - - I
��s/,� ` �CE976�718<) - �
Policy o. Compon - ��r COUNTY OF LOS ANGELES � BUILDING'AND SAFETY
� Certified copy is hereby furnished. '
FOR APPLICANT TO FILL IN BUIIDING
�errified copy is filed wi�h fhe county building Inspe[• ADDRE55 v�� �I � ���£f-G+�
lion depar�ment. � y� BUILDING J.� G" �
(' . (� ��a/�/�� ADDRESSpc�7 ,,,( 1 /Z�.�Il�vt LOCAIITY � L
Date������_' Appliconl L/ 1--/ NEAREST
CERTIFICAIE OF EXEMPTION FROM WORKERS' CIN L�(. 121P CRO55 ST,
- COMPENSATION INSURANCE aY�S� 5¢E OF ASSESSOR
TRACi LOT lOT NO. MAP e00K 7AGE PARCfL
(Tht���eHon ne�d nof b�compl�Nd�f fh�p�rmh i�fn on� iEt. uSE�N� n�wa ,��_3 7S
hundr�d dolluri(SI00)er I�f�.) . ' OWNFR ( NO � r� nq.
I cerliFy fho�in the performonce o1��r which this ��/- � (��� SVECiAI
permit is issued,I shall nof emplo�a�� on in ony manner ADDRE � � .QL ¢� O"�� CONDITIONS
so as to become s�6ject ro the�or s'�wpensation Lnws. ^ - DISiRICi StAT15TI�P.I CtA55 TYPE PRpCE55ED BY
/� CITY J Z�P C1AS5 NO. CONST.
Dofe Ap 'anl ARCHITECTOR TEL. �
NOTICE TO APPLICA . If, atter moking this Certificme of ENGWEER NO. y,�,� ��
Ezemption, you ould become sv6ject to �he WOrke�s' � " yAWATION
Campensotion rovisions of the Labor Cade,you-must fo��h- ADORESS�I�n2 . � ���
A . ,e� � tEt. �t VALIDATION
with comp wilh such provisions or Ihis permit sholl be �ONTRACTOR !Ll- !`Z`G�-/ �� �,..33l�'PJ s f��v
deeme evoked.
� UCENSED CONTRACiORS DFCLARATION LiC.
1 hereby oifi�m fhat 1 am Gcensed under provisions of Ghopter 9 ADoaE 3 • !. i 0.���//��- - S �
(commencing with Secrion 7000)of Divisien 3 a1�he Business CITY iy � -yv�i MSS C��� ��� v�.b�
and Pmfessions Code,and my license is in fpll Force and effect ��R���ON O�wORK ��-�-7�/ �
License Number �3/�� lie.Class �-S3 SWIMMING POOI LJ pA E` � ► #' � � } 'G� .
_,Op-/ I • •G0?_l! a.
Conlrocfor . - �'�"�✓ Do1e �s J-E� SPA - � FINAL II� T � .
SQ.FT. S Y � ' ' °�%G,C u U
� I am exe pr onder Sea 52E �c ZC� " O
B.BP.C.(or ihis reoson ELECTRICAI � � �- � � G�'2���� V
oa,�: p, �n nW.
Si nofure Sfeel 8 Cond�it Bonding � / , `Q_� � , ,
9 Conduils,Conducfo�s,Equipmenf r����ta� r NT z
SINGLE FAMILY 'f - —
HOME OWNER-BUILDER DECLARATION PLUMBING ► �J �7 t"Q/a ' �
I hereby o{(irm thal I am ezempl from Ihe Controc�or's Llcense �r'�`���(� � .
Low ior the following reason(Setlion 7031.5,Business and P.Trvp � � ,
Prafessions Code):
Gos System
� I,as owner o(the property,will do the pium6ing ond Anri•Syphon
elecrrical work.I,or my employses with wogas oe�heir _ . . . . . ..
sole compensorian�or a licensed contracror wili do all MECHANICAL
o�her work and the strvcture is not intended or oNered - .
for sale(Section 704d 88P Code). Swimming Pool Hea�er Q � �
CONSTRUCTION LENDING AGENCY : 2�2 G.3 A
I hereby a(Firm thal there is a mnstruction lending ogency for '
the performonce o( work!or whith this permit is issued .�, A�(PRINT) NO. ► jt• • i .i� �
(Sec.3097,Civ.C..
Lender's Nome ��{� -'�� , ADDRE55 , � °L� a 0 0
. Lender's Address � � �O� ' `�� �n�u �
P.C.Fee f �p._. Permii F<e -
I cerlify thof I hove reod Ihia oppiicolion ond srote�hvt the �p.� 7_a b
obove informo�ion is toneU.I agree ro comply wfth oll Couny ' - � �� G�ua�ce fee , � �
ardinances ond State laws relating to building, etectrical, �
mechaniml and plumbing consnucrion,ond hereby ou�horize I tnvesrgoron fee - � - �
epreseniatives ol ihis Caunty �o enter opon ihe above- � toial Fee
�lioned propert��mspeclion purposes. � '
�i�„�Tl�c l.if.�.�—t/ ,��5��
`\ Signaiure of Appli�anl or agen� Da�e � SEE REVERSE FOR EXPUNATORY LANGUAGE �
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