HomeMy Public PortalAbout8720 BURGHARDT RD_Swimming Pool__ WORKERS'COMPENSATION DECLARATIr,�N
C r or aaffirm
cenif cartI he e of Worke srtCompeosotoneInsuron el` APPLICATION FOR COMBINAT ON SWIMMING POOL PERMIT
oo certified copy thereof (Sec. 3800, Lab. C.) 76A2013
WN-81-19`� CE-875(11/81)
Policy No. Company paemot� COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING -
0Ceriifiep copy is filed with fh co g inspec- ADDRESS
tion department. BUILDING p.�t
ADDRESS S 1 ZO e)V a.1ZT LOCALITY
Date In--S " � Applicants
G NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITV ZIP CROSS ST. "Z�
COMPENSATION INSURANCE SIZE f `` ASSESSOR ,
TRACT LOT// LOT NO, MAP BOOK PAGE I PARCEL
(This section need not be completed if the permit is for onen TEL USE ZONE MAP
hundred dollars ($100) or less.) OWNER RO 2 IAi aN`1o.2�s—6025 Ni er;"
I certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS 2. A'R..T-- CONDITIONS
so as to become subject to the Workers'Compensation Laws. ( ISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ��Ott2.1' ZIP CONST.
Date Applicant ARCHITECT OR TEL CLASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
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 TEL.Z� ��rr $ It
OOa VALIDATION
deemed revoked. CONTRACTOR QL11E �I .NO./�u,S^
LICENSED CONTRACTORS DECLARATIONGC/O/p r E LFAu NOISSIo2 LIC
ADDRESS p pl .
.
I hereby affirm that I am licensed under provisions of Chapter 9 $
(commencing with Section 7000) of Division 3 of the BusinessCITY L•`rzW tG. tic, C—S3 >.and Professions Code,and my license is in full force and effect. d
DESCRIPTION OF WORK
ppCC I LP FINAL p O
License Number IVS10L. tic. Class , S3 SWIMMING POOL I�l `'
�/• 1p I I��l 1� DATE ��( p�J , ' 5 9 0.0 A IM
Controcra_�^'` yc] Date SPA LJ FINAL �j iN o 0 0 0 2 O
BY vl �C (`
50. FT. � � V
❑ SIZE W
I am exempt under Sec. Z e e 73.6 4 a
B.BP.C. far this reason ! o c o N
ELECTRICAL S d7 7 3 b'4 v
Date: �i
Signature Steel 8 Conduit Bonding 10. 1 .1 —83
Conduits, Conductors, Equipment
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING ,
I hereby affirm that l am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and p-Trap
Professions Code): Gas System ��5 9 0. 1 A
I, as owner of the property, will do the plumbing and Anti-Syphon - iEt3
0 0 0 0 0
electrical work. I, or my employees with wages as their 20 Ors rn
sole compensation,or a licensed contractor will do all MECHANICAL12
SiSZ yU( lkJ x
other work and the structure is not intended or offered
for sale Section 7044 B&P Code). -
I ) 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) C NO. ,
(Sec. 3097, Civ. C.).
Lender's Name Wo lonwk) ADDRESS _
Lender's Address
P.C. Fee$ Permit Fee '
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County {�
ordinances a Slate laws relating to building, electrical, Issuance Fee I " f l
mechanic nd tum Bing construction, and hereby authorize Investigation Fee _Ce s a%ft this County to enter upon the above- Total Fee �' yfornspection purposes. `'S licant or Agent Date SEE REVERSE FOR EXPLANATORY 1. URGE
r.