HomeMy Public PortalAbout11011 GREEN TREE LN_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I havecertificate 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)
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnis ed.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the unty buildinape ADDRESStion de artm nt. BUILDING
,ADDRESS OCALITY �
Date Applicant NEAREST r
CERTIFICATE OF EXEMP N FROM WORKERS' CITY ]� ZIP CROSS S
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 TEL USE ZONE MAP / _ _ Z
hundred dollars ($100) or less.) OWNER NO. — NO.
1 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 //40 � � /y ~l CONDITIONS
so as to become subject to the Workers'Compensation Laws. y /� DISTRICT STATISTICAL CLASS TYPE CES D BY
CITY ZIP CONST. .
' CLASS NO.
Date Applicant ARCHITECT O TEL. ✓vj ✓L
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
Exemption, you should become subjectto the Workers' ADDRESS VALUATION
Compensation provisions of the Labor Code, you must forth- .�� VALIDATION
with comply with such provisions or this permit shall be l_� TEL. s /X7
deemed revoked. CONTRACTOR L� NO. i((�J
LICENSED CONTRACTORS DECLARATION LIC.
ADDRESS �� NO. ��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
and Professions Code, andel my license is in full force and effect. DESCRIPTION OF WORK
License Number Lic. Class SWIMMING POOL - �S�V/ DA EL , }
Contractor / Date SPA Zlr4 FINAL Q�
SFT. BY
I am e mpt under Sec. SIZE
E k
B.&P.C. for this reason ELECTRICAL
Date: W
Steel & Conduit Bonding A'
SignatureConduits, Conductors, Equipment N
SINGLE FAMILY Z
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 P-Trap
Professions Code): Gas System
I, as owner of the property, will do the plumbing and AntiSyphon
electrical work. 1,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered 7 7J O 9 A
for sale (Section 7044 B&P Code). ..Swimming Pool Heater #,o 0 0 0 �,�
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TEL. ° ° 6 2 4 8
the performance of the work for which this permit is issued PRINT
(Sec. 3097, Civ. C.). ( 1 e NO. , .0 0 0 6 2.4 8 5)
Lender's Name ADDRESS /0/4 �7"1 1 0623-87
`��
Lender's Address
P.C. Fee$ . k Permit Fee 7�/ !d z / 3,1,,0 A
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County Issuance Fee # "° 0 0 • 0 3
ordinances and State laws relating to building, electrical,
mechanical and plumbing construction, and hereby authorize Investigation Fee
representatives of this Count�i� enter upon the above- Total Fee C1• .�� 0 220.50'
.
Celes rty f pe,4id os
ignature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE