HomeMy Public PortalAbout11006 GREEN TREE LN_Swimming Pool__ WORKERS' COMPENSATIOV DECLARhTION
hereby affirm that I have certificate of consent to self ' APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) 76A20B
CE876(3/84) i
Policy No. (f mpany a COUNTY OF LOS ANGELES BUILDING A74D SAFETY
QCertified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspec- ADDRESS � a�� ti•
tion department. BUILDING oo
yy�p DDRESS ((�F1 LOCALITY
Date v 1 pp cant /1 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY `C ZIP CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT O. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for oneT / USE ZONE MAP
hundred dollars ($100)or less.) OWNER �� � O. Ycrf- I7�t NO. /V
1 certify that in the performance of the work for which this / �•- / /� SPECIAL
permit is issued, I shall not empFar•any person in any manner ADDRESS J f�(p CYZG�. `+�►a /C�" CONDITIONS
so as To become subject to the Workers'Compensation Laws. Q�� DISTRICT STATISytCAL CLASS TYPE' PROCESSED BY
CITY Q 4 �c ZIP �a�/tr� CONST.
Date Applicant ARCHITECT OR
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER
Exemption, you should become subject to the Workers' ADDRESS f / 4:t.-
VALUATION
Compensation provisions of the Labor Code, you must forth- e�S �
TEL. /���� VALIDATION
with comply with such provisions or this permit shall be CONTRACTOR �/ NO• $ `� --
deemed revoked.
LICENSED CONTRACTORS DECLARATION �,t1 (('�� LIC. ss
ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 4 /V, O�Gi .Snrc� NO. J JQ Z
LIC. $
(commencing with Section 7000) of Division 3 of the Business ,�
CITY vCJ V ��JL�►. CLASS C
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
1 /f _�� FINAL !, .
License Number d C Lic. Classy, ��� SWIMMING POOL DATE 1
8 Q� K ❑
Contractor Date FINAL
SQ FT. ✓
BY Il
I am exempt under Sec. SIZE O
B.&P.C. for this reason ELECTRICAL
Date: eO
Steel & Conduit Bonding
Sinature
9 Conduits, Conductors, Equipment W
SINGLE FAMILY IL
HOME OWNER-BUILDER DECLARATION PLUMBING U)
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
P Trap
Professions Code): --
Gas System ,
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. 1, or my employees with wages as their ;F
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater r;
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
APPLICANT ,r TE
_-•:,_r:
the performance of the work for whi this permit is issued (PRINT) �
NIG�. A<GO
(Sec. 3097, Civ. C.).
/4J et-
Lender's Name ADDRESS S /4V- .f 0. V%r
..r
Lender's Address D
P.C. fee$ /��Q, Permit Fee �O r�•_,'.,E" •._c xr
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 09c,+
meth and pl bing construction, and hereby authorize Investigation Fee -•,t;•r:_r^,a t; e
// :f t: i W
re esentati e f t C unt ter upon the above- Total Fee (Gr D _
entione top f r ' spec'on urposes. -
Signature of Appli ant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE