HomeMy Public PortalAbout10310 LA ROSA DR_Swimming Pool__ WORKERS'CI have a certificate
Nif DECLARATION
7i
hereby affirm that 1 haver certificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
i1C I
nsJ re, or ti certificate of Workers' Compensation Insurance,
or a-certified copy there f Sec. 3800, Lab. C.) 76A20B .. -
/,7 CE-875(11/81)
Policy N � ompa ny T� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO ILL IN BUILDING �`
Certified copy is filed with rhe c y uilding inspec- ADDRESS o3%d C
tion d partm t - BUILDING / //jf
ADDRESS [� / f IOCALITV
Date Applica NEAREST p
CERTIFICATE OF EXEMPTIO FROM WORKER CITY ,L� ZIP CROSS 57. a-+'�---
COMPENSATION INSURANCE SIZE OFTRACT LOT LOT NO. MAP BOOK PAGE PARCEL
ASSESSOR
(This section need not be completed if the permit is for one TEL. r USE ZONE MAP �-J
hundred dollars ($100) or less.) OWNER �� N �Q Y j NO. L
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 ubject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CONST.
Dote�Appl icant- ARCHITECT OR TEL _ �/ CLASS NO.
NOTt TO APPLICANT: If, after making this Certificate of ENGINEER r f N —Q '-� i6O ..�
Exemption, you should become subject to the Workers' �•� ` A _�� ✓JQ - VALUATION
Compensation provisions of the Labor Code,'yom must forth- ADDRESS N.IG /�
with comply with such provisions or this permit shall be _ rTEL $
r^ VALIDATION
deemed revoked. CONTRACTOR J N
LICENSED CONTRACTORS DECLARATION PP �7 NO
ADDRESS o2 . pf NO
I hereby affirm that I am licensed under provisions of Chapter 9 LIC.
$
Class SWIM
(commencing w'nh Section 7000)of Division 3 of the Business CITY CLASS
and Professions Code,and my cense' in full force and effect. A.
l _ l (//ry�� DES IMO OF WORK '
License Numbed'_ Lic. SWIMMING POOL DATE/ 8s' , O
Contrac H+r�j��Date y/ a SPA
FIN k•
am exempt under Sec. SO, B - 9 9 0.3 A d
401
B.&P.C. for this reason ELECTRICAL �-v1 7 # e ° ° ° 2 1 2
Date: 2 ° ° 95 94
Steel &Conduit Bonding
Signature Conduits, Conductors, Equipment D �j ° ° ° 95 9 4'um
SINGLE FAMILY
- HOME OWNER-BUILDER DECLARATION PLUMBING 03,22-84
1 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 1990,4 A
electrical work. I, or my employees with wages as their #.e.e e ° ° 3
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered f� 2•° 2 98. 5 O
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY _ �O•° 292506
1
9 50cs.-
1 hereby affirm that there is a construction lending agency for APPLICANT - TEL. Q 3,22-84
the performance of the work for which this permit is issued (PRINT) 'NO.
(Sec. 3097, Civ. C.). - ,
Lender's Name ADDRESS --
v Lender's Address C a �j�/
P.C. Fee$ �?% Permit Fee ( Q �
I certif that ve read this application and state that the
above ormation correct. I agree to comply with all County
ordinanc t e s relating to building, electrical, Issuance Fee
mechanic and plumbin construction, and hereby authorize Invesrgaron Fee ir7lrd
represe at as of thi County to enter upon th abov Total Fee 0(
ned ra or inspection purpose,
Sign Dote 5 REVERSE F R M&ANATORY LANGUAGE
I 1.