HomeMy Public PortalAbout5225 PAL MAL AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION f 7 — a / --pK
I hl reby affcemi that I f'deW r certificate of consent to self 'APPLICATION FOR COMBINATION SWIMMING P®®d PERMIT
insures, o`•%a ceatiffcate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.) 76A20B
CE876(3/84)
Policy Compony COUNTY OF LOS ANGELES BUILDING AND SAFETY
n Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING J--
ertified copy is filed with the co my building inspec- ADDRESS
ti n de ar/rtmenf. BUILDING .q
Date 1� b Applicant ADDRESS 5ZZ �'L. /s! �• LOCALITY
NEAREST
CITY / ZIP CROSS ST.
CERTIFICATE OF EXE PTION FROM WORKERS' SIZE OF ASSESSOR
COMPENSATION INSURANCE TRAC LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one `� TEL. 7_71
E MAP ^�
hundred dollars($100)or less.) OWNER. 140 116-10-a, NO. -+ NO. / �N 0
I certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person in any mgnner ADDRESS , . . ' CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PRO ED BY
CITY ZIP CONST.
CLASS NO.
Date Applicant ARCHITECT OR TEL. D O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. c (/
Exemption, you should become subject to the Workers' r VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS -
with comply with such provisions or this permit shall be $
1 VALIDATION
TEL. �q� .�
deemed revoked. CONTRALTO 71 NO.Z?_Z� IJV`/
LICENSED CONTRACTORS DECLARATION �+��y LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS apv{p �T(�il1L,, NO. 15smz $
(commencing with Section 7000)of Division 3 of the Business CITY �p�p^rj{, r CLASS►—S-1
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
p FINAL J
License Number iL7S��Z Lic. Class C— SWIMMING Po DATE
Contracto Date s Oi SPA V�'� � yOU 05956 A
SQ.FT. 9 # 000023 V
I am exempt nder Sec. SIZE &_
0 0
B.BP.C. for this reason ELECTRICAL ) Q 3 b
Date: 0 0 - 9Q366 w
Signature Steel 8 Conduit Bonding ' 1,18-86 �
Conduits, Conductors, Equipment
SINGLE FAMILY Z
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 EE5 9 5 7 A
Professions Code): Gas System
El I, as owner of the property, will do the plumbing and Anti-Syphon # 0 0 0 0 0 3
electrical work. I,or my employees with wages as their ° 2 9 Q G 5
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered ° ° 2 9 0.2 5 5for sale (Section 7044 B&P Code). Swimming Pool Heater Q
CONSTRUCTION LENDING AGENCY , 1, 18-86
1 hereby affirm that there is a construction lending agency for APPLICANT TEL. �r
the performance of the work for which this permit is issued (PRINT) Pool NO.
(Sec. 3097, Civ. C.).
Lender's Name am_— ADDRESS $�(p (Ci r-�►�(,r,
Lender's Address P.C.Fee$ G•3Z
Permit Fee
I certify that I Acive read this application and state that the
above information is correct. I agree to comply with all County
ordinances a State s relating to building, electrical, Issuance Fee
mechanical nd plu in construction,and hereby autfv
ize Investigation Fee
represent ves of is County to enter upon t ae- Total Fee
me proper f inspection purposes.
>11 1of i%12.01
ign re of ant or Agent D e SEE REVERSE FOR EXPLANATORY LANGUAGE