HomeMy Public PortalAbout5017 ARDEN DR_Swimming Pool__ WORKERS' COMPENSATION DECLARATION - � C
hereby affirm that I have a certificate of consent to self \ APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or ", cert'f'cate ofof W rkers' Compensation Insurance``or y t J '�" 3800, b C.) 76A OB
CE-Poli yo. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
e lifted copy is filed with t e ount buildi inspec- ADDRESS �
io de,a t t BUILDING �
ADDRESS �� LOCALITY
Do Applicant ( —
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY IP CROSS SL
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO.5
MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one TEL. USE ZONE LSPECIAL
hundred dollars($100)or less.) OWN NO. / �. Q
1 certify that in the performance of the work for which this i permit is issued, I shall not employ any person in any manner ADDRE NS
so as to become subject to the Workers'Compensation Laws. DISTRICT. STATISTICAL CLASSYPE PROCE ED BY
CIT IP CLASS NO. ` ONST. �.
Date Applicant ARCHI CT TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINE NO. pa.��y "' / r
Exemption, you should become subject to the Workers' /1�! VALUATION r }
Compensation provisions of the Labor Code, you must forth- ADDRESS CJ lJ J/
with comply with such provisions or this permit shall be j o /}t_� TE $ O (` v VALIDATION
deemed revoked. CONTRAC wti—;:) �! \
LICENSED CONTRACTORS DECLARATIONLIC.
C
DDRE / 1 NO
I hereby affirm that I am licensed under provisions of Chapter 9 $
(commencing with Section 7000) of Division 3 of the Business LIC.
and Professions C d d ryyy hce is in full f� ect. DESCRIPTION OF WORK CLASS. 1126
(`J\J DATEFINAL r ,
License Number Lic. Cla SWIMMING POOL
�.
lho
Contr to Dat SPA I SO. FT. FINAL .� r (
✓ !❑ I am exempt under Sec. SIZE
BY z'9 QC? A \�
B.&P.C. for this reasonb _` a'o 0 0 2 1
ELECTRICAL _
Date:
Steel & Conduit Bonding r_ ° 1 2 5 8
Signature '
SINGLE FAMILY Conduits, Conductors, Equipment '1 2
_
HOME OWNER-BUILDER DECLARATION PLUMBING , O 1 9'-8 4
I hereby affirm that I am exempt from the Contractor's License pt '
Law for the following reason (Section 7031.5, Business and P-Trop
Professions Code): Gas System
ElI, as owner of the property, will do the plumbing and Anti-Syphon i 7 / �� 8 p,9 A
electrical work. I, or my employees with wages as their ! /
sole compensation,or a licensed contractor will do all MECHANICAL ;` a o 0 0 0 3
other work and the structure is not intended or offered ` t
for sale (Section 7044 B&P Code). Swimming Pool Heater ,2 -.21 8 6 3
CONSTRUCTION LENDING AGENCY LN
I hereby affirm that there is a construction lending agency for APPLICANT 1 TEL .<
the performance of the ork for which this permit is issued (PRINT) N - PooJ. 1 9-9 t!
(Sec. 3097, Ci . C.).
Lender's Name 5\1 ADDRfSy
Lender's Address p.C.Fee$ /.2 PermitFee V 13
I certify that I have read this application and state that the
above inform ' n is corr I agree to comply with all County
ordinances nd ate law relating to building, electrical, Issuance Fee s
mechani and pl mbing onstruction,and hereby authorize Investigation Fee { v 2
represen tives o this C unty to enter upon the above- Total Fee ( (/ 6J
mentione rt f r in pection purposes.
4AL9_111
Signature of Applicant or Agent Date ?SE%E=ERS �OREXPLAItTORY LANGUAGE \