HomeMy Public PortalAbout5324 FRATUS DR_Swimming Pool__ - r
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•" t W�13KERS'COMPENSATION'DECLARATION
I' �F�t,;, y a;firm that I have a certificate of consent to self
m �eiAPPLICATION FOR ,COMBINATION'SYYIMMIIVG�'P, PERMIT
or
a certificate of Workers' Compensation Insurance, c OOL -
or a cert yJl-opy the-e f (Sec 380P76A20B
, La C )
osjvv K6y�, CE876(3/84) 'm
Policy No Company COUNTY OF-LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN BUILDING
�Cert,fied copy is filed with�t�re my b �Idmg„m pef� ADDRESS
hon;ye artment /� �,I UDRESS
ADDRESS LOCALITY
pore Applican .r-++ � � r NEAREST
CERTIFICATE OF EXEMPTI ji`FROM WORKERS' CITY �/ �GF— �' ZIP 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 I TEL MAP IV-7"
_ ��
hundred dollars ($100) or less ) OWNER Z N NO
I certify that in the performance of the work fo? which this SPECIAL- ,
permit is issued, I shall not employ any person in any manner ADDRESS , T�� /2il.�C' CONDITIONS
so as-to become subject to the Workers'Compensation Laws I DISTRICT STATISTICAL CLASS' TYPE PROCESSED BY
CITY �-�c 'i,ZIP
Date Applicant ARCHITECT O CONST TEL /)Y CLASS NO ,�
NOTICE TO APPLICANT If, after making this Certificate of ENGINEER 'K !S NO V 000-
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS /4e
with comply with such provisions or this permit shall be ' // TEL $ VALIDATION
deemed revoked CONTRACTOR( �//g� O / /
LICENSED CONTRACTORS DECLARATIONADDRESS O/� NO LIC
/i/(G;y,� /S'�2�
I hereby affirm that I am licensed under provisions of Chapter 9 LIC $
(commencing with Section 7000) of Division 3 of the Business CITY CLASS _ ;2 0 8 IL 9 A
and Professions Code and my license is in full force and effect DESCRIPTION OF WORK
FINAL # 0 0 0 0 2,1
�5��L7 Lic Classe-453 lk }
License Number SWIMMING POOL DAT `.
��., �iAGi7� (�oo1-s J�,7 ��— ✓ I 'm - 9 S 9 5'
Contractor ate OO SPA /� F AL O
❑ SQ FT JBY / o o � 9595c=i (�
11 am exempt under Sec SIZE / 10,0 6 s 8 8 C)
B&P C for this reason ELECTRICAL
Date
Steel &Conduit Bonding 0.
Signature I Conduits, Conductors, Equipment
SINGLE FAMILY ?
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031 5, Business and
Professions Code) Gas System
t 0 8 `a O A
1, as owner of the,property, will do the plumbing and Anti-Syphon f #,0 0 0 0 a 3
electrical work 1, or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL 1 - 333,00=
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 (PRINT) f! 4,41 P �p
(Sec 3097, Civ C ) \
y7 I
Lender s Name ADDRESS
Lender's Address 11{
PC 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 and State laws relating to building, electrical Issuance Fee I
mechanical and plumbing construction, and hereby authorize Investigation Fee �� r mil
reeresentotives of this Cou to en r upon the above- Total Fee C/
me A r y t7�^n ur ses
a
Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE ,