HomeMy Public PortalAbout9823 HOWLAND DR_Swimming Pool__ WO.RKERS',COMPENSATION DECLARATION
hereby o4wm that I have a certificate of consent to self APPLICATION FOR-COMBINATION SWIMMING POOL PERMIT
insure,^or'a certifimie of Workers' Compensation Insurance,
or a certified copyahar of (Sec. 3800,11_0C.) 76A20B
CE8"(3/B4)
Policy No.ji Company wy,� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
ADDRESS <707-3 t_sL• GGA-'t_+.
T tion d part 'em y
I`¢ BUILDING 1� �.
Date �I Applicant �'L I� ADDRESS C ~ �' OgREST
C part
OF EXEMPTION FROM WORKERS' CITY Gb �, ZIP CROSS OR
COMPENSATION INSURANCE SIZE ASSESSOR d� PARCEL D6
TRACT LOT LOT NO. MAP BOOK O PAGE
(This section need not he completed If the permit is for one , TEL. USE.ZONE MAP
hundred dollars ($100)or less.) OWNERr QX NO, 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 '�/� CONDITIONS
so as to become subject to the Workers'Compensation Laws. +,.� 1 DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY Vs, '-
Date Applicant ARCHITECT O ZIP TEL, t ryt GLASS NO:R CONvST.
NOTICE TO APPLICANT: if, after making this Certificate of ENGINEER L , T 1{ NO c7'O / '• -��
Exemption, you should become subject to the Workers' ' VALUATION,
Compensation provisions of the Labor Code, you-must forth- ADDRESS ��//LL,�,, -�1r�� VALIDATION
with comply with such provisions or this permit shall he CONTRACTOR IL- y,A` QiJS •NOLUSZA $
deemed revoked.
UC
LICENSED CONTRACTORS DECLARATION ADDRESS �.1,�w) NO.J'bSko,
I hereby affirm that I am licensed under provisions of Chapter 9 �.
�} UC. //'' $
(commencing with Section 7000) of Division 3 of the Business CITY W �•V✓' CLASSV�,
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
FINAL
License Number J�{ IQZ> Lia Class_ SWIMMING POOL DATE
Contractor WIL i(I � Date Z SPA SO. FINAL
F .❑
By CL
I am exempt under Sec SIZE 'V 0 O
U
8:8P.C. for this reason ELECTRICAL -
Date: O
Signature Steel 8 Conduit Bonding
Si 0
9 Conduits, Conductors, Equipment
SINGLE FAMILY d.
HOME OWNER-BUILDER DECLARATION PLUMBING ^3 U
I hereby affirm that I am exempt from the Contractor's License ® �� Z
Law for the following reason (Section 7031.5, Business and I :{:T,A
Professions Code): P,-Trop ACCT.
Gas System 3307
1, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I, or my employees with wages as their 'D
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered F1GCT.t
for sole (Section 7044 B&P Code). Swimming Pool Heater -C
CONSTRUCTION LENDING AGENCY 33i37 `71.29
I hereby affirm that there is a construction lending agency for APPLICANT . TEL.�/ /, s n ITEM'?
the performance of the work for which this permit is issued (PRINT) ,
(Sec. 3097, Civ. C.). , TOTAL. b 14 $u
Lender's Name ADDRESS x LVs""� -
C4ECY, 614.8_`;
Lender's Address CHANGE .Cil
P.C. Fee S OS O(• / Permit Fee �T'
I certify that 1-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 O ^�
mechanical and plumbing construction, and hereby authorize Investigation Fee �' OOOO-0001 8/2 /�'d
representatives of this unty to enter upon the above- Total Fee 5�7 i AM ` 137
mens Toned property for pection purposes. rL 1 1111
W zs
Signature of A pGc t or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE