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WORKERS'CQMPENSATION DECLARATION
I hereby affirm that I have o 4ificate'Ef consent Io'self
Insure, or'a certificate of;Workeri
Compensation lnsu.ancp, APPLICATION-FOR COMBINATION SWIMMING POOL•PERMIT- ' II(JII
or a.certified copy thereof,(Sec. 3800, Lab. C.) 76A209'
W t4. flD� •O� CE876(]/B4)
Policy, o. mpony (-�X�L�L COUNTY OF LOS ANGELES _.. BUILDING AND SAFETY
.F Certified copy is hereby furnished.'
BULL
FOR APPLICANT TO FILL IN : RD O
Certified copy tfiled with the county building inspec- - ADDRESS -
tion department.. BUILDING ��
ADDRESS" L/TS/ i LOCALITY
Date Applicant - / /� NEAREST - - •
CERTIFICATEOF EXEMPTION FROM WORKERS' CITY _TFzP14G ` ZIP f_V CROSS ST. - - -
' COMPENSATION INSURANCE LOT OF ASSESSOR P
,
TRACT LOT LOT NO.. MAP BOOK _ PAGE ARCEL
(This section need not be completed IF the:permitis for one TELUSE,ZONE MAP --- .
hundred dollars (9100)or less:) OWNER �_ NO. NO. _ �-
-certify that in the performance of the work for which thisJ�. SPECIAL' -
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 ;iLlDgATION .
CITY ZIP +I'. I
F�
CLASS NO Dole Applicant ARCHITECT OR TEL fLr y3 j' ,NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.Exemption„ you should became subject to the Workers' - - - VAWATIO C O61
Compensation provisions of the Labor Code; you,must forth- ADDRESS .`
With comply with such provisions or this permit shall be �'''' // TEL. $-
deemed revoked: CONTRACTOR Pkt4 , OCA .NO. ' s
,
LICENSED CONTRACTORS DECLARATION
,I•hereby affirm that I am licensed under provisions'of Chapter 9 ADDRESS 04-E J 02
(commencing with Section 7000) of Division 3.of the Business _ - LIC.
CITYCLASS-r-93
and Professions Code,and my license is in full force and effect '
• _ DESCRIPTION OF WORK _ � FINA
License Numher Lic. Class POOL DATr1 I�J,
I D '
4L4F PMt-`� R. "71,90
r
Contractor Date —�� SPA ,,s FINA ! `
I am exempt under Sec. SIZE �(YD - - - BY a0
B.BP.C. for This reason - - - ELECTRICAL - - O
Date: -
Steel 8 Conduit Bonding- U
Signature Conduits, Conductors, Equipment - ' - .z '• - ls.l
SINGLE FAMILY U)
HOME OWNER-BUILDER DECLARATION PLUMBING . ', - Z
I hereby affirm that I am exempt from the Contractor's License j '
Law for the following reason (Section 7031.5, Business and - - -
Professions Cdde)i _ Gas System .. - ..._.:.�� -( v - '. 'AC:CT i '
1, as owner of the property;will do the plumbing and Anti-Syphon 3307 ?9?,71
electrical.work. I,or my employees with wages as their - , . -
sole compensation,or a licensed contractor will do all MECHANICAL : 1 IfEt1a
other work and the structure is not intended or offered - - -
for sale (Sectiod'7044 B&P Code). Swimming Pool Heater - Tf.11AL. 292 - 71
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for + _ - } CHECK 292.71_
the, erformance of the'work for which'this ermit is issued APPLICANT TEL, s - -
P - P (PRINT) CHANGE
•OU
(Sec. 3097, Civ. C). - - . . _
Lender's Name ADDRESSXV%9
1/29/9Ci
00110-0101..,
Lender's Address
. P.C. Fee S Permit Fee VL q _ PjC''i�. ':1 , .AM10-07 '
I certify that I have.read this application and state that the .
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Is
Fee 13 , 0 O -
'mechanical and plumbing-construction, and hereby authorize Investigation Fee ��E1_ - - -'
• representatives of 1 County to enter upon-the above- Total Fe N
' ment' ed property o spection purposes. -
n
Ig ure of App cant r ge Date SEE REVERSE FOR EXPLANATORY LANGUAGE -