HomeMy Public PortalAbout8728 BURGHARDT RD_Swimming Pool__ ,4
.sl• WO CATION DECLARATION
hereby
ereb WO a have a certificate of consent to self
insA, or a cenifica - of Workeri mpensotion Insurance, APPLICATION FOR COMBINATION SWIMMING POOL,PERMIT
or a certified copy thereof (Sec. 38 Lab. C.) 76A20B
p�/y� CE-875(11/81)
Po' No. Company S 7T T Ts/ COUNTY OF LOS ANGELES BUILDING AND SAFETY
ertified copy is hereby furnish d. r,I
" BUILDING 4C��
ertified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS
tion departm ant. BUILDIN
ADDRESS LOCALITY P
Date \�\ Applicant ZLS,b3J
CITY I NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' 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 NO. ,/) NO.
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 BLKC4 (� CONDITIONS
so as to become subject to the Workers Compensation Laws. DISTRICT STATISTICAL CLASS . TYPE PROCESSED BY
CITY Z l` CONST.
Date Applicant ARCHITECT OR TEL �s V CLASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO, 3
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 TE . s VALIDATION
deemed revoked. CONTRA .N
LICENSED CONTRACTORS DECLARATION
ADDRESS O. J
I hereby affirm that I am licensed under provisions of Chapter 9 f
(commencing with Section 7000) of Division 3 of the Business LIC Q
CES - CLASS O I Y
and Professions Coe a license is in full force aqd effect, d
DESCRIPTION OF WORK FINAL //J ► 1 8 9. 1 q y
License Number ic. Class� � SWIMMING POOL DATE �rJ
MM 0
Conlrocto I. �. SPA FINA M o 0 0 0 2 3 Q
OSO. R. 8Y 4 ( o - 8 4,,7 9 W
I am exempt under Sec. SIZE S
B.BP.C. for this reason ELECTRICAL o 0 0 8 4,7 9 mo Z
Date: 04. 1 9-85
Signature Steel 8 Conduit Bonding
SINGLE FAMILY
Conduits, Conductors, Equipment
1 R O Z
HOME OWNER-BUILDER DECLARATION PLUMBING {1 Y 3
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 703).5, Business and , I - 29550
Professions Code): P-Trap
Gas System '
1, as owner of the property, will do the plumbing and Anti-Syphon o - 295505
electrical work. I, or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL - L 1 9-85
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
the performance of the work for which this permit is issued TEL
(Sec. 3097, Civ. C.). (PRINT) NO.
Lender's Name - ADDRESS ,
Lender's Address 610P.C. Fee 8 N/ Permit Fee DU t
I certify )hal I have read this application and store that the
above information is correct. I agree to comply with all County
ordinances and Stale lows relating to building, electrical, Issuance Fee �U L
mechanical and plumbing construction, and hereby authorize Investigation Fee
leesentalives of this County to enter upon the above- Toml Feetioropertyforinspection purposes.f Signora e o A.Plicom or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE