HomeMy Public PortalAbout10305 LA ROSA DR_Swimming Pool__ t 7 3
WORKERS'CO/4iPtENSATION DECLARATION 'I I
' hereby,°ffce, fhm "aver certificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT ul
insure, or a cerfificbte of Workers' Cam pensattgn Insure
or o ter tied copy there f (Sec..380 , Lab. C.)- 76A20B -
/ CEB76(3184)
P°IicylF�°Y7.1_ rompany .COUNTY OF LOS ANGELES BUILDING ANDSAFETV
.Certified copy is hereby furnished. 1 _
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the - unty b ildin9 inspec- -' ADDRESS k030'
lio dep fnyen t. ' BUILDING C
�V'1 Uyl]��, ADDRESS D 0.,7 OCALI
Date _�Applim nt NEAREST
CERTIFICATE OF EXEMPTION FROM W KE CITY ZIP CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT `f LOT LOT NO. . MAP BOOK PAGE PARCEL
.(This section need not be completed if the permit is for one TEL U _ E MAP .n ^/O
hundred dollars ($I00) or less.) OWNER NO. NO a2�
I certify that in the performance of the work for which this �1 SPECIAL
permit is issued, I shall not empty any person in any manner ADDRESS C4,-, CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE P CESSED BY
CIT ZIP ® CONST.
Dote Applicont ARCHITECT TEL CLASS NO.3�
J'
NOTICE TO APPLICANT: If, after making this.Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, youmustforth- ADDRESS 7/ VALIDATION
with .comply with such provisions, or this permit shall be TEL' bb S 1 1 —
deemed revoked. - CONTRAC .NO.
LICENSED CONTRACTORS DECLARATION / 1 LIC
hereby affirm that ADDRESS am licensed under provisions of Chapter 9 LIC. (, f
(commencing with Section 7000) of Division 3 of the Business CITY CLASS
and Professions Code, and my license is in full force and effect. DESCRIPTION OF WORK
r a, FINAL
U u her uc. classC� swlM LNG Pooi S pe+ onrc _ 2� 5 4 0 9 A
C^,y' Ar/ To } 0
C frac r Date SA #SOP F7. �� 6Ye.e'a e '21 U,
I am exempt under Sec. SIZE ( ° - 7364
O
B.&P.C. for this reason ELECTRICAL - '° °'° 73.6 4 v
Date:-- 09..10_86 1 O1
Steel 8 Conduit Bonding - •
Signature Conduits, Conductors, Equipment c 5 4 1.0 A z
SINGLE FAMILY
HOME OWNERBUILDERDECLARATION PLUMBING - 4 is is e is e 3
I hereby affirm that Iam exempt from the Contractors License -
Law for the following reason (Section 7031.5, Business and P Trap ( ° 2 5 Q 0 0
Professions Code):" Gas System s
1, as owner of the property, will do the plumbing and Anti-Syphon ° -° 2 5 a 0 0 ux
_ electrical work. I, or my employees with wages as their . ,- - .. _
sole compensation,or a licensed contractor will do all MECHANICAL 0 9. 1-0`8 6
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code)! Swimming Pool Heater
CONSTRUCTION LENDING IGENCY
hereby offirm that there is a constructicill lending agency for APPLICANT TE
the performance of the work for whi this permit is issued (PRINT) NO
(Sec 3097, Civ, C�
Lender's Name ADDRESS W
Lender's Address
P.C. Fee$ ;73Permit Fee +
I certify that I have read This application and state that the
above information is correct. I agree to comply with of County
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical and p umbing construction, and hereby authorize Investigation Fee ^f O� -
rep res 1 es o this County to enter up the above- Total Fee ,--S + p - r..r
ment ned opert for inspection purposes.
Signature o4 Applim or gent ! Date SEE REVERSE FOR EXPLANATORY LANGUAGE