HomeMy WebLinkAbout0000A 0070ARKERS' COMPENSATION DECLARATION
that I have a certificate of consent to self
rtificate of Workers' Compensation Insurance,
copy thereof (Sec. 3800, Lab. C.)
1
Company
Srtified copy is hereby furnished. s
J Certified copy is filed w' county building inspec-
I n de artment.
Date Applicon
CERTIFICATE OF EXEMPTION FR WO ERS'
COMPENSATION fNSUR
C(This section need not be completed if the permit is for one
dollars ($108) or less.)
1 certify that in the performo he work far which this
permit is issued, I shall note toy erson in any manner
so as to become subject to the orkers' pensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, offer moki this C tificate of
Exemption, you should become subj t to t Workers'
Compensation provisions of the Labor Co e, you must forth-
with comply with such provisions or this permit shot) be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
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 I Lit. Class
Contractor Date
F1I am exempt under Sec.
BAP.C. for this reason
Date:
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
law for the following reason (Section 7031.5. Business and
Professions Code):
ElI, as owner of the property, will do the plumbing and
electrical work. I, or my employees with wages as their
sole compensation, or o licensed contractor will do all
other work and the structure is not intended or offered
for sale (Section 704E BSP 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.
is N
Civ.. )`,
A Lender's Name N L v
tender's Address
I certify that I hove 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,
mechani lumbing construction, and hereby authorize
repre motives o rhjs County to enter upon the above.
menl ned pro0 fctian purposes.
APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
76A208CE876 (31841
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR( APPLICANT TO FILL IN AUDIESS _CC J' -R- L,1,JC >-7
BUILDING L
ADDRESS 4 } t LOCALITY 9A %J9
NEAREST
CITY n,Af3 ,n ZIP CROSS ST. -
SIZE OF ASSESSOR
TRACT r LOT l0T NO. MAP BOOK PAGE PARCEL
TEL. USE ZONE MAP
OWNE aemNO. NO.
7 •'j —7y 'r
ADDRESS C.-uS{
SPECIAL
CONDITIONS
STATISTICAL CLASS TYPE PROCESSED BY
CIT ZIP
J CLASS NO.
CIXJST.
Fsr ARCHITECT OR TEL.
ENGINEER ltr NO.
ADDRESS
1
VALUATION
VALIDATION
TEL.NO. CONTRACTOR
UC.
ADDRESS 0 NO.
0000ALIC.
CITY CLASS
flNALyayn 1DESCRIPTIONOfWORK
SWIMMING POOL DATE U.%
t • •60,211
SPA FINA
50. FT. / / BY // n e (`: Q G tt
SIZE X07 L sJ" vaV
I /T Zeg j - f 1
0720-88
ELECTRICAL -
Steel 8 Conduit Bonding
Conduits. Conductors, Equipment
PLUMBING
P -Trap
Gas System w2 0 0 h r AAnti -Syphon
MECHANICAL 1) • • ° • • J
Swimming Pool Heater 2 1 3. !) 0
21x00
07.22-88
APPLICANT TEL.
PRINT) - ., NO.
ADDRESS
0i2-2 TDP.C. Fee S `P Permir Fee L7
IssuanceIssuance Fee
Investigolion Fee .[
TOIaI Fee iQ
Signnrurc oTApplicam or AI nil ` Dnle SEE REVERSE FOR EXPLANATORY LANGUAGE
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