HomeMy Public PortalAbout10709 LA ROSA DR_Swimming Pool__ "1 WAKERS' COMPENSATION DECLARATION
hereby affirm tial have �erti amof consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
,,.censure, or-6'certificate of Workers' Compensation Insurance,
r a cern ie ,co thereof )Sec. 3 ab. C.) 76A20B
� �`` CEB]613/B4t
ity`Na. Company ''�� COUNTY OF LOS ANGELES - BUILDING AND SAFETY
tCertified copy is hereby furnished.fished.
FOR APPLICANT TO FILL IN BUILDING
ified copy is filed with the county buildinq inspec ADDRESS
department. LD NG gDDRESS- tl LOCALITY
Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY i kJ s, ZIP CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT lOT LOT NO., 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.) r OWNER NO. x % NO.-
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 CONDITIONS
so as to become subject to the Workers'Compensation Laws. � DISTRTCT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP L Y 7 CONST.
Date Applicant ARCHITECT OR TEL. �_ �/ CLASS N O.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. D
Exemption, you should become subject to the Workers' VALUATION of
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be M�sT _ f t VALIDATION
QQ
deemed revoked. - CONTRACTOR .N- -
LICENSED CONTRACTORS.DECLARATION L C.
ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 LIC� � $
(commencing with Section 7000) of Division 3 of the Business CITY - CLASS
and Professions O e my license is in full for ear a an DESCRIPTION OF ORI
License Number Lic. Clas SWIMMING POOL '' /1 //� 9 U - DATE �' '/I' ► y� p q�0 }.{
SPA V„M1 o� l Iz/ 1 04
Contract r �e FIN // /1
❑ SO. FL By I e e 8y❑� y.z 9 U
am-,
under Sec. I SIZE T L/ s s e (}G, / 9 p.'
B.BP.C. for'this reason ELECTRICAL `// 05Q 2-85 O
Date: t ` 1,9 7.Q A LU
Signature Steel 8 Conduit Bonding . .
g Conduits, Conductors, Equipment N
SINGLE FAMILY _ - # e o • o s x3 z
HOME OWNER-BUILDER DECLARATION PLUMBING , I e 29a.50
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and P Trop
Professions Code): Gas System 1 • • 29 5 505
I, as owner of the property, will do the plumbing and Anti-Syphon I.
electrical work. I,or my employees with wages as their _ 0 a02-85
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TEL.
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C-). (PRINT) NO.
- Pool Name ADDRESS '
Lender's Address 1��� OD
P.C. Fee E L ( Permit Fee
I certify that I hove read this application and state that the Q s s-0above information is correct, agree to comply with all County --
ordinances and State laws relating to building, ele<Irical, Issuance Fee
echanical and plumbing construction, and hereby authorize Investigation Fee � n \ I
re a enfatives of this unty to enter upon the above- Toml Fee U A
en ' erty fo ins ec ' purposes. t
J
nature of AppSmm or Agem Date � SEE REVERSE FOR EJ(PLANATORY LANGUAGE