HomeMy Public PortalAbout5233 PAL MAL AVE_Swimming Pool__ S'COMPENSATION DECLARATION
Le that I have r certificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
certificate of Workers'Compensation Insurance,
0 opy thereof(Sec. 3800, Lab. C.) 76A40B
CE-875(t t gat 1 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polic `-'Company
ert,fied copy is hereby furnished.
BUILDING
Certified copy is filed with the county building inspoc- FOR APPLICANT TO FILL IN ADDRESS _ �� Ck
tion department. BUILDING j526r /
p� ADDRESS LOCALITY `. _ \I
Date v Applicant 42)� NEAREST
CITY ZIP �� CROSS ST, ee
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE O ASSESSOR
COMPENSATION INSURANCE TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for onoTEL. USE ZONE MAP
hundred dollars($100)or less.) OWNER NO. NO
I certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP /� CLASS NO: CONST. ^ n
Date Applicant ARCHITECT OR TEL. L
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
with comply with such provisions or this permit shall be �,/ TE S` j� $ ,�I�. VALIDATION
deemed revoked. CONTRACTOR W� NO LLLL 23
LICENSED CONTRACTORS DECLARATION LIC.
ADDRESS _S O. {, a ffi
I hereby affirm that I am licensed under provisions of Chapter 9 LIC. ; 7 a
(commencing with Section 7000)of Division 3 of the Business ",t i
CITY � CLASS •.t.lf
and Professions Code,and my license is in full force and effect. „,rte., dL
/��r��r,,,2 DESCRIPTION OF WORK FINA f. ,t.t:.t L
License Number/�l� Lic. ClasS� SWIMMING POOL S�i'� �f 3 r� V
q r a t ,T DATE , �4. t.. 1/`76�28
Contractor==. Date SO. FT �i BY e ' +_ gyp
SPA Er FINAL :._ _}. 176aL��Jyy 0
AM ru
I am exempt under Sec. SIZE � �/� � C�}{�lj�, s �
#A
B.&P.C. for this reason ELECTRICAL G t t�
Date: 'O'DOG 3(.}91 5/2i'Y°/8
Steel &Conduit Bonding
Signature ;.`i;r"
SINGLE FAMILY Conduits, Conductors, Equipment w. ..,l MU
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
1 sole compensation,or a licensed contractor will do all MECHANICAL _
other work and the structure is not intended or offered r, `
f)•-ale (Section 7044 B&P Code). Swimming Pool Heater ,:,'LfS"�
CONSTRUCTION LENDING AGENCY TTI"rn`-,
I hereby affirm that there is a construction lending agency for APPLICANT -�= -^�
the erformance of the work for which this permit is issued ��//(( xxL TEL. �J i'�r. `.,kq.i�+�° { 54
P P (PRINT) I s�lM2 J NO..G�{�J` 4L
(Sec. 3097, Civ. C.). Poot.r + y • �:
Lendor; ,'lame ADDRESS
Lancer U 'V S, �� (f
l : Address
P C Fee$ i Permit Fee
I cerhf� that I have read this application and state that thei 5/24/d
Issuance Fee
above i tformation is correct. I agree to comply with all County � `'-'��%-
ordirance•, and State laws relating to building, electrical, i •I(.o,
mechanical and plumbing construction,and hereby authorize Invetitigation Fee "' w � � ���'!'
1,1,11.4_
representatives of this County to enter upon the above- Total Foe _5r,
mentioned pro r for inspection purposes.
J
Signature o App ant o Agent Date SEE REVERSE FdR EXPLANATORY LANGUAGE