HomeMy Public PortalAbout4936 ARDEN DR_Swimming Pool__ WORKERS'COMPENSATI N DECLARATION �0
I hereby affirm that I hav-1-1certi{ are.,sof consent to self
gn�ure, or-ba certificate of Workerfi,.c�ompensation Insurance, APPLICATION -FOR COMBINATION SWIMMING POOL PERMIT
ol�"a certified copy thereof (Sec. 3800, Lab. C.) 76A20B
^' ��� 71AA0 CE876(3/M)
Policy NoG ,=�-ny / COUNTY OF LOS ANGELES BUILDING AND SAFETY
C,r.,, ted copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING /
Certified copy is filed with the county building inspec- ADDRESS
tion department. BUILDING 1J17 `
G !-� ADDRESS GC1�- LOCALITY
Date % 2- Applicant �/ [/� NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY ' ZIP CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one -� TEL. USE ZONE MAP
hundred dollars ($100)or less.) . OWNER r NOW44518 NO.
I certify that in the performance ofthe work for which this �,/ SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS v /-� ^ ' CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE SSED BY
CITY ZIP CONST.
Date Applicant ARCHITECT OR TEL-' ' CLASS NO. �.
NOTICE TO'APPLICANT: If, after making this Certificate of ENGINEER , . N r�/r`! -
Exemption; you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you"must forth- ADDRESS d" y (i�"7�� �C�L
/ TEL. /�/�, VALIDATION
with comply with such provisions or this permit shall be CONTRACTO��y �/J C�®G1 N.3,(7- (p q 4- ; 00
deemed revoked•:
LICENSED CONTRACTORS DECLARATION LIC. `�C/� �/
f
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS W NOBS LIC. r � $
(commencing with Section 7000) of Division 3 of the Business CITY �(�� CLASS(.
and Professions Code,and my license is in full force and effect. '
PDESCRIPTION OF WORK FINAL
License Number Lic. Class SWIMMING POOL / DATE
7-3
ContractorDate j `( SPA tJ la� FINA 2� �o��q6 V
7/Y �-r 7 7
SFL BY
I am exempt under Sec. SIZE W: � 0�
e' C7
B.&P.C. for this reason ELECTRICAL a
Date: .0 6 2 3 8 7 W
Si nature Steel &Conduit Bonding
g Conduits, Conductors, Equipment
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING 2 7 3 0 7 A
I hereby'affirm that I am exempt from the Contractor's License # o o o • ® 3
Law for the following reason (Section 7031.5, Business and P-TrapQ
Professions Code): Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon
0 electrical work. 1,or my employees with wages as their 0 6,2 3d
. 8 7
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered
for sale (Section 7044 B&P Cade). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TEL.
the performance of the work for which this permit is issued (PRINT) NO. ,
(Sec. 3097, Civ. C.).
Lender's Name - ADDRESS
Lender's Ad ss
P.C. Fee$ Permit Fee
I certify th t I have read tl is application and state that the �U
above info ma ion is I agree to comply with all County v
ordinances n tate law lating to building, electrical, Issuance Fee
mechanic d plumbing co truction, and hereby authorize Investigation Fee !�
re rese atives of Co ty to enter upon the above- Total Fee33 0
men ' ned prop f pection purposes.
�j _-
Sign to - Date SEE REVERSE FOR EXPLANATORY LANGUAGE