HomeMy Public PortalAbout10335 LA ROSA DR_Swimming Pool__ WORKERS'COMPENSATION DECLARATIONS �II
he e, affirm that hover certificate Comte of consent
ion Int to =elf APPLICATION FOR COMBINMIOsY SWIMMING POOL PERMIT ILII
insure, or a certificate of Workers' Compensation Insurance,
or a certifie{`copy thereof (Sec. 3800, La C.) /T 76A20B -
1 OJ l �,�,_ / CEBi6 l3r8�1
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished. /Jr e / - _J`
BUILDING / 33�' �"�'� l ' lcl �_�/L.
a .Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS GL'
Jlon department. / BUILDING m
/n •C/ q ADDRESS 10 3 3 S H l`tasA (/ LOCALITY
Do 12�Applicon rrvJJl/7 L T�i� ��� F NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' L(7 Oiv C� L �y z I P CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR /9 ✓ Q ✓ 5/
TRACT LOT LOT NO. MAP BOOK JO PAGE1941O PA L
(This section need not be completed if the Permit is for one n^ ^y�J/ `t�O q/O p USE ZONE MaP y�/ 7�
hundred dollars($100)or less.) OWNER /1/I/-f 4 vlkLC� A NO. /
I certify that in the performance of the work for which this Q o 3S� l/� 6 Q SPECIAL
permit is issued, I sholl not em any person in any mo er ADDRESS I J `/7 F- �/' �� -/ CONDITIONS
so as t become subject to the a ers'Co ensation s. �/' ��+ DISTRICT STATISTICAL CLASS ' TYPF PROCESSED BY
(//�
CITY-7 e / C to/ ZIP CLASS NO. CONST.
Date /�A lico 't > ARCHITECT O A T� v j
NOTICE TO APPLICANT:pf, afte mak ng this Certificate of ENGINEER /! P 2 p0 L✓✓LGt�-t ��
Exemption, you should become ject to the Worker, '/ `�- VALUATION
Compensation provisions of the Labor Code, you must for - ADDRESS N ��i /�TT�Epp ��`` J 00 ' B yt' v VALIDATION
with comply with such provisions or this permit shall he CONTRAC de' J' .N6 /w- / $ V
deemed revoked. ,
IC.
LICENSED CONTRACTORS DECLARATION -'T(- . :?J�(�?
ADDRESS /] 744- O NO. S3'
I hereby affirm that I am licensed under provisions of Chapter 9 LIC / S
(commencing with Section 7000) of,Division 3 of the Business CITOZLf E'1 e I �� f%/f�rn LA
and Professions/"Code, and my license its in full force and effect. DESCRIPTION OF WORK
l� `J�-�S16 /jJ I -�� FINAL ,
License Num/bn"er c Class SWIMMING POOL DATE r „ 'Lt."
�� ��� Dare L - / _ SPA /ate
M� y / FINAL }{
COnt C o V
SO. FT.
EJ 8Y
am ex under Sec. SIZE A O
B.8 .C. for th s reason ELECTRICAL L f�"1'r'p?���y
Date: W
Si n Steele& Conduit Bonding � �
9 Conduits, Conductors. Equipment Z
S FAMILY '
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
Professions Code): P Trop
Gas System 11C,.07�
❑ I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I, 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 In1.l'.1 °T
for sole (Section 7044 BSP Code), Swimming Pool Heater -`t i? 4;;;'1,x.?
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 1 Ftrl-'
APPLICANT (�' TEl (� �^ _
the performance of the work for which this permit is issued (PRINT) d, n ° NO. J'��/" TOTAL -'F9- m
(Sec. 3097, Civ. C.). ( - -iL.
Lender's Name ADDREss/ 75/7 f�{ � . _1
' ` I
CHECK c
Q._
Lender's Address �)isY '.HfPaL
D.C. Fee E _I
'
li
Permit Fee ✓ , .
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
ordinances and State laws relating to building, electrical,
26K
mbin consteby authorise Investigation FeeJth' myTotal Fee �C5 // � �'='�� ' AM1i"'-'f
r specticom or Agem Dme SEE REVERSE FOR EXPLANATORY LANGUAGE