HomeMy Public PortalAbout10440 LA ROSA DR_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I haver certificate of tion Int 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.) 76A2DB -
MdN 8A--jRgd$ CE875(I1/81)
Policy No.-+ Company Pale LAo�T' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
BUDING
FOR APPLICANT TO FILL IN ADD
Certified copy is filed with the county building inspec- ADDRESSRESS
Zo T T .[_
.dno�_dde/Ip_c�1Yt tp�m.,('e�1LInt. BUILDING 11 /J A
Date�Applicant ADDRESS 10440 k.Ar ' los A: � NEAREST
�ICERTIFICATE OF EXEMPTION FROM WORKERS' CITY Te r ZIP gQ CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO. Y MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one TEL USE ZONE MAP
hundred dollars ($100)or less.) OWNER �7aV`Le V%C� NO. — NO C> O/ O'
I certify that in the performance of the work for which thisSPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS toLkg0 LA Q-0 Ss CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROC SSED BY
CITY
T c1 ZIP �� 0 CONST.
Date Applicant ARCHITECT OR TEL. L� CLASS NO. -
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. S.o ..��
Exemption, you should become subject to the Workers' VALUATION
Compensation,provisions of the Labor Code, you-must forth- ADDRESS
with comply with such provisions or this permit shall be n 11 TEL. 11 $ 1 2 Oil60 VALIDATION
deemed revoked. CONTRACTOR P \ _NO.ZflS- 1 7
LICENSED CONTRACTORS DECLARATIONUC
(,,,JtST(rAQ. NO. IBSIC)Z
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS $
(com encing with Section 7000) of Division 3 of the Business _ LIC' C— >.
((�� CITY CLASS S�
and Fyu�essions Code,and my license is in full force and effect d
DESCRIPTION OF WORK FINAL O
G--S 3 ► u
License Number$AS��Z� tic Closs SWIMMING PO L DATE �
/s 11 ((++ _ _ 22z-9� o
Contractor`Al s` Q�O� Date- 7.. SSl FINA V
I am exempt under Sec. SIZE BY .9L
N
B.&P.C. for this reason ELECTRICAL z
Date:
Signature Steel& Conduit Bonding2 9.7 2 A
Conduits, Conductors, Equipment
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING'. ' ' 2 1
I hereby affirm that I am exempt from the Contractor's License , 2 0(e 8(( '7 9
Low for the following reason (Section 7031.5, Business and I P-Trap'
Professions Code): Gas System 1e o e £?1L.7 9 5
I, as owner of the property, will do the plumbing'and Anti-Syphon x;7,2 5�—Cg'4
electrical work. I, or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL 2 9 �,.3 F{
other work and the structure is not intended or offered
for saleSection 7044 B&P Code). - # e.e to
( ) Swimming Pool Heater a ej r L ,
CONSTRUCTION LENDING AGENCY _ 2•e 27�•:7 S
I hereby affirm that there is a construction lending agency for APPLICANT ,/�
the performance of the work for which this permit is issued (PRINT) TEL NO. , 'o °,2 7 3.'7`,G,.=
(Sec. 3097, Civ'. C.).
Lender's Name ADDRESS 0-7,25-84
Lender's Address
1 Permit Fee
.
I certify that I have read this application and state that the P.0fee S CJ
above information is correct.I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical and plumbing construction, and hereby authorize Investigation Fee -7
repres totives of this County to enter upon the above- Total Fee (/' �� r
menti ed property r inspection purposes. '
stare of A cant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE