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WORKERS'C'rPENSATION DECLARATION
hsrre'�y affYfj1':.;.
toI have r -certificate n tionse sero ,elf :' APPLICATION FOR COMBI�tATION SWIMMING POOH PERMIT
Insure, or aof Workers' Compehsgtlon Insurynce,
or a .r11#ledpy 1 ereof S c. 3800, Lab.,C.
Policy. No om rfy F-�O # S COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certlfldd copy Is hereby furnished.
BUILDING ¢n l
MXCertified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN ADDRESS OoG L N
tlon department. BUILDING
DateAppllcan ADDRESS F LOCALfrY
NEAREST
CERTIFICATE OF EXEMPTIO FROM WORKERS' CIN TW ZIP CROSS 5T.
COMPENSATION INSURANCE
fSZE OF ASSESSOR
TRACT T LOT NO. MAP BOOK PAGE PARC3
Is sa-'"— read not be completed H the permit Is for an*
TEL ZONE MAP
undnd dollars(=100)or leas.) pyyt,ER tV0 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 CONDn-K)NS
so as to become subject to the Workers'Compensation Laws. DtSTR STA CLASS TYPE BY
T1'
CZIP V CLASSCLASSNO.
CONST.
Date Applicant ARCHITECT OR TEL f 1/V1�
NOTICE TO APPLICANT: If, after making this Ceritflcate of ENGINEER NO. V
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 CONTRACTOR NCO : tJ�, VALfDATION
deemed revoked.
LICENSED CONTRACTORS DECLARATIONAt)DRE55 r{Qa tl � � Z
I hereby affirm that I am licensed under provisions of Chapter 9 v�u L $
(commencing with Section 7000) of Division 3 of the Business CLASS
and Professions Code,and my Ilcerne Is In full force and effect. crTY,DESCRIPTION OF WORK
/� A MAL ,
License Number�l�� Llc. CIauS�� SWVr5M1tJG POOL DATE '
Contracto ie PlG�5 Date SPA RNAL
SQ. FT. q {Y
ElI am exempt under Sec. SIZE
B.BP.C. for this reason ELECTRICAL
Date: r r
'Steal 8 Conduit Bonding I ✓�I
Signature Conduits, Conductors, Equipment
SINGLE FAMILY Z_
HOME OWNER-BUILDER DECLARATI0N PLUMBING
I hereby affirm that I am exempt from the Contractors License 3
Law for the following reason (Section 7031.5, Business and P-Trap ACCT�
A
Professions Code): Gas System i�i■
I, as owner of the property, will do the plumbing and Anti-Syphon 37 1
Tj
electrical work. I,or my employees wjth wages as their
sole compensation,or a licensed contractor will do all MECHANICAL 1 ITEM
other work and the structure Is not Intended or offered
for sale (Section 7OL" B8P Code)_ Swimming Pool Heater TOTAL . 1-71 -75
CONSTRUCTION LENDING AGENCY (1EC{ 171.7
I hereby affirm that there Is a construction lending agency for –
the performance of the work for which this permit Is Issued �� .00
(Sec. 3097, CIV. C.). '
Lender's Name
04�D -0001 1,�1M/ 63/89
Lender's Address P'C. Fee f Permit Fs. p b�1 1 t1 I 7;1,r-1
1 ceriify that I have read this application and state that the
above Information Is correct. I agree to comply with all County hwanc*Foe 0
ordinances and State laws relating to building, electrical, v
mechanical and pl tubing construction,and hereby authorize Investigation Fee
representatives his County to enter upon the above- Total Fee
oned pro rt r Inspection purposes.
tura o I n or nt Dote SEE REVERSE FOR EXPLANATORY LANGUAGE
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