HomeMy Public PortalAbout9711 GARIBALDI AVE_Swimming Pool__ WQR�RS'.COMPEWbATIGNJ DECLARATION
}ergby a c . that I haver certificate of cion Insurance,to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
+nsure, or a certlflcate of Ww�Cen' Compensation Insurance,
w a c copy t roof (Sec. 3800, b. C.) CEB76
S( cr=epe(3ia+)
Poll o. Compan COUNTY OF LOS ANGELES BUILDING AND SAFETY
entified copy Is hereby furnished.
W
ertlfled copy Is filed with the county building Inspec- FOR APP NT TO FILL IN BUILDING
tion department. 16eBUILDING
ADDRESS I/ ZV4LOCALTIY
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION F M WORKERS' C ZIP CIS ST.
COMPENSATION INSURANCE SIZP OF ASSESSOR
MAP
(TSIs section need not be completed If Am permit Is for one TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
hundred dollars($100)or less.) TEL USF�{Ot NO.
L^ . I NO.
I certify that In the performance of the wdrk for which this SPECIAL
permit Is Issued, I shall not employ any.pemon In any manner ADDRESS CONDITKWS
to as to become subject to the Workers'Compensation Laws DISTRICT STATISTICAL CLASS TYPE PROCFSSf)BY
CRY ZIP �- ryy ICLASS NO I
Date Applicant ARCHITECTOR TEL• fV,r s//[K1
NOTICE TO APPLICANT: If, after making this Cerflficate of ENGINEER NO.
Exemption, you should become subject to the Workers' VALUATION
Compensation prov.lslons of the Lob-or Code, you must forth- ADDi55
with comply with such provisions or this permit shall be - TEL /n 0,C) VALIDATION
deemed revoked. CONTRACTOR
LICENSED CONTRACTORS DECLARATION
I hereby affirm t,at I am licensed under provisions of Chapter 9 ;
(commencing with Section 7000) of Division 3 of the Butslness UC.
and Professions Code,and my license Is In full force and effect. CTTY CLASS
DESCRIPTION OF WORK MNA1 r
License Numbe ',`���� Llc. ClassS
AMMING POOL /i, �j /f#p/ � DAn ` Z
d b
Contractor Date �— SPA 7 MN
V O
Fr. U
I am exe pt under Sec. SIZE
-43549A o
B.BP.C. for this reason . Rf-CTRICAL U
000
Date:
Signature Steel 8 Conduit Bonding # 021
Conduits, Conductors, Equipment � J a 0 6 8 0 5
SINGLE FAMILY Z
HOME OWNER-BUILDER DECLARATION PLUMBING o ,,o 6 $0 5 5
I hereby affirm that I am exempt from the Contractors License - ,
Law for the following reason (Section 7031.5, Business and P-Tra - -1 1,26 1$5
Profenions Code): Gas System L�J
I, as owner of the property, will do the plumbing and i Anti-Syphon
electrical work. I,or my employees with wages as their
sole compensation,or a licensed contractor will do all )MECHANICAL ;@ 3 5�0 A
other work and the structure Is not Intended or offered 4
for sale (Section 70.4.4 B.&P Code). j Swimming Pool Heater # 0 0 0 s 0 3
CONSTRUCTION LENDING AGENCY J - 239.26
1 hereby affirm that there Is a construction lending agency for APPLICANT TEL
the performance of the work for which this permit Is Issued (PRINT) NO. , • - 239.266
(Sec. 3097, Cly. C.).
Lender's Name gpppf� J.•1,2 6"8 5
Lender's Address P.0 Fee f Perm Fee
I certify that I have read this application and state that the 1�,S
above Information Is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, 11s'ancs Fee
mechanical and plumbing construction,and hereby authwixe InvvsNgotion Fee n `
representatives of this Co my to enter upon the above- Total Few QJ 7 C/J
m tinned property fo Ion purposes.
Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE
I - -