HomeMy WebLinkAbout0000A 0070A (4)RKERS' COMPENSATION DECLARATION
that I have a certificate of consent to self
rtificate of Workers' Compensation Insurance,
copy thereof (Sec. 3800, Lab. C.) f
Company
Rtified copy is hereby furnished. s
J Certified copy is filed w' county building inspec-
nI
n de ortment.
Date( ` t Applicon
CERTIFICATE OF EXEMPTION FR WO ERS'
COMPENSATION fNSUR
hta radion need not be completed if the permit is for oneT
ondrad dollars ($108) or lass.)
I certify that in the performo he work for 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, after moki this C tificate of
Exemption, you should became subj t to 1 Workers'
Compensation provisions of the Labor Co e, you must for
with comply with such provisions or this permit shall 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
F1I am exempt under Sec.
B.SP.C. for this reason
Signature
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 a 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. 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,
mechani lumbing construction, and hereby authorize
repre motives o rhjs County to enter upon the above.
menl ned pro0 fctian purposes.
TeAzaD
APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
CE876 (31841
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR( APPLICANT TO FILL IN C( JBUILDING ' (GtiQC'> AUDIESS
LPAADDRES4 }•{ LOCALITY %J9 ('
NEAREST
CITY ZIP CROSS ST. -
SIZE OF ASSESSOR
TRACT r LOT LOT 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 BYDISTRICT
Clip,ZIP
J CLASS NO.
CIXJST.
Fsr ARCHITECT OR TEL.
ENGINEER -& NO.
ADDRESS
1`/
VALUATION
VALIDATIONTEL.
CONTRACTOR NO.
UC.
ADDRESS 0 NO.
0000ALIC.
CITY CLASS
flNALyayn e 1DESCRIPTIONOfWORK
SWIMMING POOL DATE
I • •60,211
SPA FINA
SO. FT. / / By // n e 6Q C 4SIZEL
1 /T - f l
0720-88
ELECTRICAL -
Steel 8 Conduit Bonding
Conduits. Conductors, Equipment
PLUMBING
P -Trap
Gas System w2 0 0 h r AAnti -Syphon
MECHANICAL 11 • • . • • J
Swimming Pool Heater 2 1 3, 00
21x00
APPLICANT TEL.
PRINT) - ., NO. oil.
07.22-88
ADDRESS
0i 2P.C. Fee S `P Permit Fee
Lfs''
Issuance Fee
Investigolion Fee .{
Total Fee iQ
Signntwe o Applicam or A nt Dare SEE REVERSE FOR EXPLANATORY LANGUAGE
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