HomeMy Public PortalAbout9509 LA ROSA DR_Swimming Pool__ DECLARATION
hey by AKER:'ACOMPENSATION
m that I have a certificate of consent to self FOR COMBINATION SWIMMING POOL PERMIT u
insure, or a ceiificate of Workers' Compensation Insurance, APPLICATION
o'wr Ia certified c•9py theree,' (Sec. 3800, Lab. C.) l6A2013
13- 1 D/ j` CE67613'84, COUNTY OF LOS ANGELES BUILDING AND SAFETY
�ol cy Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the co y building inspec- ADDRESS _
tion department. BMING ^
ADDRESS [A
5 LOCALITY
Date _Appl ica NEAREST
CITY ZIP CROSS ST. r
CERTIFICATE OF EXEMPTIO FROM WORKERS' SIZE Of ASSESSOR
COMPENSATION INSURANCE TRACT LOT LOT NO. MAP BOOK P E PARCEL
(This section need not be completed if the permit is for oneTEL. USE ZONE MAP r
hundred dollars ($100)or less.) OWNER V,A' � NO.&gAco, r NO. j a
I certify that in the performance of the work for which thisT�11 �_/ SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS SVLA \ CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY T CLASS tJO.
ZIP _� (I CONST
Date Applicant ARCHITECT OR TEL. _ /
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. J(
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS
TEL � VALIDATION
with comply with such provisions or this permit shall be $
deemed revoked. CONTRACTORCAUNd'/J ��fi(!J
LICENSED CONTRACTORS DECLARATIONLIC.
ADDRESS NO.JjSJ2=D
I hereby affirm that I am licensed under provisions of Chapter 9 LIC $
(commencing with Section 7000) of Division 3 of the Business CITY CLAS j
and Professions Code, and my license is in full force and effect. DESCRIPTION OF WORK
FINAL
License Number /('Q ? Lic. Class SWIMMING POOL 1 q �q DAT (� 0 M ►
/^,�/ I 9�7 �j r Y1 IBX/
Contractor Q`vr� �1-5Date �— !✓ SPA tv t FINA -O
SQ. FT. J�� BY U
1 am exempt under Sec. SIZE 0::
U
B.&P.C. for this reasonELECTRICAL ~
U
Date: W
Signature Steel & Conduit Bonding a'
Si
9 Conduits, Conductors, Equipment e
z
SINGLE 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 P-Trap
Professions Code): 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 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 (PRINT) NO
(Sec. 3097, Civ. C.). ` ,
Lender's Name ADDRES / 1
Lender's Address
P.C. Fee$ �V Permit Fee I
I certify that I have read this application and state that the
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
representatives of this County to enter upon the above- Total Fee t.
mentioned prope ty for inspection purposes.
1 1:110
gnature of Apph ant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE