HomeMy Public PortalAbout9940 LA ROSA DR_Swimming Pool__ C*RKE;S':Of•APE615AA,N DECLARATION
surel o u4Pcenfifico Mover certificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
insure, or a ceitificote of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) 76A20B
��,^�,/T CE976(3/B4)
Policy N B Company /! NJJ COUNTY OF LOS ANGELES BUILDING AND SAF TY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the my b Idling inspec- ADDRESS tl
tion department. BUILDING /h /'
7 ADDRESS c/,J LOCALITY
Date Appli< (t NEAREST
CERTIFICATE OF EXEMPTION FROM WOR CITY /r�/� ZIP �(l 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 rSIFECIAL
P
hundred dollars ($100) or less.) OWNER ��' N — /1 I .I certify that in the performance of the work for which this 7Y�—permit is issued, I shall not employ any person in any manner ADDRESS NDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PR SSED BY
CITY ZIP CONST
Dale Applicant ARCHITECT NO OR � -• TEL
ENGINEER ` CLASS NO�
/„JLC J
NOTICE TO APPLICANT: If, after making this Certificate of `/ O/ O
Exemption, you should become subject to the Workers' gDDRE55 _�� JS VALUATION
Com ensation provisions of the Labor Code, you must forth- 7 O b oO VALIDATION
with comply with such provisions or this permit shall be _ TEL
deemed revoked. CONTRACTO
LICENSED CONTRACTORS DECLARATIONc LI
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESSp NO $ el?4 9.6 A
(commencing with Section 7000) of Division 3 of the Business CITY CLASS 3ii
and Professions Code, and my license is in full force and effect. DESC IPTI NOF WORK ~ • • • • 2
I��}�[ FINAL , 'I • . 6805
License Number Lic. Class C�,/y—/���j�/�•-�" SWIMMIL DATE AVAa
Contract - / Dole_ SPA r J �+ FINAL • • • 6 P.O 5 R
O SFT. V
am exempt under Sec. SIZE BY 0 5 2 8
2 —8 8
B.BP.C. for this reason ELECTRICAL
Date: W
Signature Steel 8 Conduit Bonding 'jp`dS�CI. U)
g Conduits, Conductors, Equipment z
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING ►
hereby affirm that I exempt from the Contractor's License
Low for the followingg r 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. 1,or my employees with wages as their Nr
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered
for sale (Section 7044 B8P Code). Swimming Pool Heater 129 :5 9 4 9. 7 A -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for • • is • • 3
the performance of the work for which This permit is issued APPLICANT TEL.PRINT
(Sec 3097, Civ. C.). (PRINT)
NO. � •) - 239,26
Lender's Nome ADDRESS2. s
• • 39, 26
Lender's Address /•T/ ) 0 5�2, 8 8
P.C.Fee S LV Permit Fee
certify that h e rea his application and state that the
above'mformati is correc agree to comply with all County !� SV
im=
laws relating to building, electrical, Issuance Fee umb g nstruclion, and hereby authorize Investigation Fee o I C umy to enter upon the above- ioml Feeer or ' spection purposes.- /L/ Do�i�a X// SEE REVERSE FOR EXPLANATORY LANGUAGE