Loading...
HomeMy Public PortalAbout5327 ARDEN DR_Swimming Pool__ ' ^WC)KERS'COMPENSATION DECL,4RATION I ht�e -6ffiern .r^r••t I have a certificaterof consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT insure, or a certificote of Workers' ComN.fnsotion Insurance, fe,rtified rt ' d cqt of (Sec. 3 Lab.•C.) 76A20B CE-875(11/81) . a• company COUNTY OF LOS ANGELES BUILDING AND SAFETY rtified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING copy is filed with the county building inspec- ADDRESS department. BUILDING'S ADDRES LOCALITY Date Applicant r9 NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CITY " IP 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 E MAP �7 hundred dollars($100)or less.) OWNER!' NO. NO. C>4- 1 certify that in the performance of the work for which thisSPECIAL permit is issued, I shall not employ any person in any manner ADDRESS CONDITIONS so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE P SED BY CITY C ZIP ST. Date Applicant ARCHITE T OR TEL. /��©6 CLASS NO.�/ O� NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. J Exemption, you should become subject to the Workers' VALUATION Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or this permit shall be r ` E $ VALIDATION deemed revoked. CONTRAC LICENSED CONTRACTORS DECLARATIONW)l LIC. ADDRES NO. I hereby affirm that I am licensed under provisions of Chapter 9 $ (commencing with Section 7000) of Division 3 of the Business LIC. CITY CLASS S' and Professions y license is in full force and effect. DESCRIPTION OF WORK FINAL - 0 License Number Lic. Cla� SWIMMING POOL (Q @9 DATE l Coniracaix� at SPA � fAl SQ. FT. V (� El1 am exempt under Sec. SIZE ' Nf B.&P.C. for this reason ELECTRICAL \ o Date: Signature Steel & Conduit Bonding Conduits, Conductors, Equipment z 2 3 L'1 A SINGLE FAMILY HOME OWNER-BUILDER DECLARATION PLUMBING '#'o a o 0 2 1 I hereby affirm that I am exempt from the Contractor's License Low for the following reason (Section 7031.5, Business and P-Trop , ( o o'9 0,3 6 Professions Code): Gas System I, as owner of the property, will do the plumbing and Anti-Syphon 0 0 o O 0 3 6 T electrical work. I, or my employees with wages as their sole compensation,or a licensed contractor will do all MECHANICAL .0624-85 other work and the structure is not intended or offered for sale (Section 7044 B&P Code). 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.). ' , ;223 1,2A Lender's Name ADDRESS # 0 0 0 0 0 3 Lender's Address 90,34—permit �•7 P.C. Fee$ Fee � / ° 3 1 4,26 1 certify that I have read this application and state that the above information is correct. I agree to comply with all County J J� ° ° I �,C 6 v ordinances and State laws relating to building, electrical, Issuance Fee mechanical and plumbing construction, and hereby authorize Investigation Fee 2— 0 624-85 fm, resentotives of this County to,renter upon the above- Total F63 e 'on operty for in tion purposes. Signature of App cant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE i 04I