HomeMy Public PortalAbout5125 PAL MAL AVE_Swimming Pool__ :'"eWORKERS'COMPENSATION DECLARATION -
I J4reby'affiPm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or a certified copy thereof(Sec. 3800, Lab. C.) 76A20B
CE-875(11/81)
�Poli o. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
�ertified copy is hereby furnished.
rtified copy is filed ounty building inspec- FOR APPLICANT TO FILL IN ADR SS
tion epart nt. BUILDING sr
ADDRESS lY LOCALITY
Date A plica NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY `e a ZIP CROSS ST.
COMPENSATION INSURANCE SIZ 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
�g
hundred dollars($100)or less.) OWNER �j Q�� NO. — NO.
I certify that in the performance of the work for which thisq� SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS 1 ZS . 9� I1t L CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY- V-e c j ZIPr� CONST.
Date Applicant ARCHITECT OR TEL. �((—3 CIASS NO.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. �\
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you.must forth- ADDRESS [[ VALIDATION
with comply with such provisions or this permit shall be CONTRACTOR .s. g �� p 7t NO. 76 76 $
deemed revoked.
LICENSED CONTRACTORS DECLARATIONLIC.
�� _6Lv NO. 329 S"79
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS LIC $
(commencing with Section 7000)of Division 3 of the Business & L,.4- CLASS B
and Professions Code,and my license is in full force and effect. CITY 2tS/t �
DESCRIPTION
OF WORK FINAL ���J ►
License Number -312o S 7 g Lic. Class SWIMMING POOL � DATE_5
U�
Contractor `Q ate S— 8 S'' SPA O
SQ. FT. r // BY A u a a a,e
I am exempt under Sec. SIZE � # IL
_eL
B.&P.C. for this reason ELECTRICAL t�. �. Z3IF ( o 1 4550
Date:
oa14550�
Steel
8 Conduit
Signature Conduits, Conductors,ors, Equipment
SINGLE FAMILY 0 a29-i-85
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 ADDRESS
Lender's Address J� 0
P.C.Fee$ Permit Fee � s(J
1 certify that I have read this application and state that the —
above information is correct. I agree to comply with all County /y
ordinances and State laws relating to building, electrical, Issuance Fee V, .S
mechanical and plumbing construction,and hereby authorize Investigation Fee
representatives of this County to enter upon the above- Total Fee S
rye�i ned propert r or inspection purposes.
/ Sig Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE
_ cY