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WORKERS'COMPENSATION DECLARATION - '• - 7% '
I hereby'a certificate
that havecertificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMITlure, or a certificate of Workers'
P9
kers'Compensation Insurance,
or a certified copy thereof IS 3800, L b. C.) '76A40B - -.
CE-875(11/81) -
P❑ollcy pified copy is he. Company < '^` COUNTY OF LOS ANGELES BUILDING.AND SAFETY
ertreby furnished.
BUILDING
FOR APPLICANT TO FILL.IN.
Certified copy is filed with the county building inspec- ADDRESS
I ion deparime nt. BUILDING -
r� i ADDRESS (/� -.J / �.Lz�'1.C� ��� - LOCALITY
Date / Applicant /- �•
<�� NEAREST
CERTIFICATE.OF EXEMPTION FROM WORKERS' CtT G_ L ' -_ ZIP ' CROSS ST. �1yCLi
COMPENSATION INSURANCETRACT LOT LOT NO. MAP BOOK PAGE PARCEL E OF ASSESSOR
�;�
(This section need not be completed i4 the permit is far one L TEL. USE ZONE MAP q
hundred dollars ($100) or less.) : OWNER " ..�.� ,�LGG� N0.�7 - NO.
I certify that in the performance of the work for which this- 1 SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS Q-[�q�Ld/ - CONDITIONS
so as to become subject to the Workers'Compensation Laws. / n (STRICT STATISTICAL CLASS TYPE PROC SSED 8Y
CITY ✓y,. C ZIP �^ CONST.
Date Applicant ARCHITECT /nI / / TEL. CLASS NO. /
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER 5.4 NO. Q7 /
Exemption, you should become subject to the Workers ADDRESS A2 � VALUATION
Compensation provisions of the Labor Code, you must forth- < D O
with comply with such provisions or this permit shall be Jn TEL ?/fZ f VALIDATION.
deemed revoked. - CONTRACTOR P QC /- NO. -36(�
LICENSED CONTRACTORS DECLARATION uC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS .�,� j t N0�3/ Z_ $
(commencing with Section 7000) of Division 3 of the Business _ LIC. qq
CITY C ,� L-++'L� CLASS
and Professions Code,and my license is in full force and effect, d
'/ / ^ DESCRIPTION OF WORK / FINAL !// y�j/f O
License Numberr���rZ,E+ Lic Class L SWIMMING POOL �Q c{^' D V
p �" //_' OATE U
6C{' �D-YG„ /yJ I S0. FT �1 �v FINAL 1 3 2�Z A 1-
SPA
ConiraClO! Date ,/� _ �r-�� W
El I am exempt under Sec SIZE 1 1/ By
�-- 111 .�.� #.o so de e 2 1 IL
N
B.BP.C. for this reason ELECTRICAL Z
Date: ,2�°.° 4.9.09
Steel 8 Conduit Bonding - 0 0 0 4 9.0 9 s
Signature Conduits, Conductors, Equipment F
c SINGLE FAMILY o _ • '0 51 '80-8 4
HOME OWNER-BUILDER DECLARATION PLUMBING -
1 hereby affirm that I amexempt from the Contractor's License
Law for the following reason (Section 7031.5, Business.and P-Ta - ✓
Professions Code): - Gas S ,
Gas System
I, as owner of the property, will do the plumbing and Ann-Syphon c 1 -14 2 3 A
electrical work. I, or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL # oro'a e o 3
other work and the structure is not intended or offered t
for sale (Section 7044 B&P Code). Swimming Pool Heater 57 b-" 2'0.1 '6 1.75
CONSTRUCTION LENDING AGENCY
hereby affirm that there is aconstruction lending agency for ° O 1 '61.755
APPLICANT TEL
- - ' --
the performance of the rk for which this permit is issued (PRINT) NO.
(Sec 3097, Civ. C.).
Lender's Name �'1-C�� / ADDRESS -
Lender's Address �r -
P.C. Fee$ /r Perm It Fee /�4
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,
Issuance Fee -
mechanical and plumbing construction, and hereby authorize Investigation Fee
representatives of this County to enter upon the above- I Total Fee -
ment+onrany for inspection purposes. -
Signowre of Applicant or Agent Dote SEE REVERSE FOR EXPLANATORY LANGUAGE