HomeMy Public PortalAbout10465 LA ROSA DR_Swimming Pool__ WORKERS'-COMPENSATION DECLARATION
hereby affirm certificate
I haver certificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a certificate of Workers' Compensation Insurance,
orp cpyjfi�d��opy,I�r�rof (Sec. 3800, Lab. C. CE816 - - -
Poli No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspec- ADDRESS -
lio de rtmen t. BUILDING
ADDRESS Lq A- LOCALITY
Date Applicant // NEAREST
ERTIFICATE OF EXEMPTION FROM WORKERS' Cliv Tem+ /� - f' ZIP 9� D CROSSOR
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE I PARCEL
(This section need not be completed if the permit is for one TEL jJ� USE ZONE MAP
hundred dollars($100)or less.) OWNER A. NOWT – y�/L NO.
I certify that in the performance of the work for which this �ss F/ . I SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS Q 5 LA '&SA /� CONDITIONS
so as to become subject to the Workers'Compensation Laws. T ^� DISTRICT STATISTICAL CLASS' TYPE PROCESSED BY
CITY / 1• ZIP ,/ U 7� CLASS NO. rST
Date Applicant ARCHITECT OR- TEL SC(.O ' vow
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' ADDRESS VALUATION
Compensation provisions of the Labor Code, you must forth- {/L� VAUDAT N
with comply with such provisions or this permit shall be TEL. �yJ��4c 5 1'{ 000O
deemed revoked. CONTRACTOR /� NO. �ZZG T
LICENSED CONTRACTORS DECLARATION pyy LIC'SD� L//( NO.1p s S�OZ
hereby affirm that ADDRESS am licensed under provisions,of Chapter 9 LIC `T 5
(commencing with Section 7000) of Division 3 of the Business CITY CLASS CvV
and Professions Code, and my license is in full force and effect. DESCRIPTION OF WORK
t�5 t02 J FINAL ,
License Number Lia Clas SWIMMING POOL ® DATE ��'
1—g(oSPA - }fFIN �42'1.2A o
Contract p Date V SO FT. C^ BY .'f • • 4 U U
F] lam ezem tun er Sec. SIZE rJ�J • • • 9 x O
B.BP.C. for this reason ELECTRICAL - 0 31 2`86 U
Date: - - LLI
Signature Steel$ Conduit Bonding EL:
N
9 Conduits, Conductors, Equipment - 4 2 1.3 z
a
SINGLE FAMILY # • • • • • J
HOME OWNER-BUILDER DECLARATION PLUMBING iI • 3 1 Q 2 6
I hereby affirm that I am exempt from the Contractor's License , • • Q x
Law for the following reason (Section 7031.5, Business and 3 p U
Professions Code): P Trap
Gas System
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 . . .
for sole (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY ..
hereby affirm that there is a construction lending agency for APPLICANT TEL.
the performance of the work for which this permit is issued (PRINT) NO.
(Sec. 3097, Ci, C.). C
Lender's Name v ADDRESS r L
Lender's Address
P.C. Fee$ Permit Fee ✓t
I certify that I have read this application and state that the _
above information is correct. I agree to comply with all County /'
ordinance and State log-cone rlating to building, electrical, Issuance Fee (J tJ
mechani d plu struction, and hereby authorize Investigmion Fee
reprTof
%Appt
9A,�n
to enter upon the above- Total Fee
on purposes.
Dile SEE REVERSE FOR EXPLANATORY LANGUAGE