HomeMy Public PortalAbout5241 PAL MAL AVE_Swimming Pool__ WORKEtS COMPENSATION DECLARATION71
hereby o Ger that 1 have a certificate ns consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT lul
insure or o certificate of Workers Compensation Inmranc
or a certified copy thereo Se 3800 Lab C ) B
CEe7 137841
Policy o try COUNTY OF LOS ANGELES BUILDING AND SAFETY
Cern ied copy is hereby furnished
RD S
Certified copy n filed with the county budFOR APPLICANT TO FILL IN BUILDING
ding mspec ADDRESS /
non deportment BUILDINGADDRESS S 7-4 1 A I cE A A `r LOCALITY
Dote Applicant T ` N`K NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS CRY 1 i;jZIP CROSS ST
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO MAP BOOR PAGE PARCEL
Is stolon need not be completed R the permit Is for omplEl USE ZONE ANP
undyed dollen(LIDO)or leu ) OWNER 4 LJp /J NO
I certify that in the performance of the work far which thisC pA, SPECIAL
permit is issued I shall not employ any person in any manner ADDRESS J l `� — CONDITIONS
so as to become subject to the Workers Compensation Laws -17. DISTRICT STATISTICAL CLASS CCTYYPEE555 PROCESSED BY
OTC 21P V �c /NECLASS NO (/
Dote Applicant ARCHITECT OR TEL c/Vryp IID
NOTICE TO APPLICANT If after making this Certificate of ENGINEER NO
Exemption you should become subject to the Worker \ VALUATION
Compensation provisions of the Labor Code you must forth- ADDRESS
with comply with such provisions or this Permit shall be CONTRACTOR 5 F E VALIDATION
deemed revoked
LICENSED CONTRACTORS DECLARATION LIC \ AN-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO v-'-' S
(commencing with Section 7000)of Division 3 of the Business 1A55 LIC 7
and Professions Cade and my license is in full force and effect CITY (yti(` Cc 'SJ
/s �'� DESCRIPTION OF WORK FINAL r7
License Number w Uc Class��c' SwvAMING POOL (CJ DAIl (JJ� ►
q//{..7 '.y�"�/ 5 zza9 a
Contractor Dale SPA FIN O
❑ so PT �� B ()
I am exempt and Sec SIZE
B 8P C for this reason0 4 4 772 3
ELECfRKAI
Dote Steel 8 Conduit Bonding i • • 7f CL
Signature Conduits Conductors Equipment Z
SINGLE FAMILY 021 21 —8 6 _
HOME OWNER BUILDER DECLARATION PLUMBING ►
4(1 7.8 A
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and P-Trop
Professions Code) Gos System g e e e e e 3
ElI as owner of the property will do the plumbing and Anti-Syphonn I 025800
eleciricol work I or my employees with wages as the
sole compensation,or a licensed contractor will do all MECHANICAL !nx1 s
other work and the structure is not intended or offered
for sale (Section 70" BdP Code) Swimming Pool Heater O O
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for APPLICANT TEL
the Performance of the work for which this permit is issued (PRIM) NO ►
(Sec 3D97 Civ C I , n
Lender s Nome ADDRESS S
Lender s Address ���
P C Fee S 73 . Permit Fee
I certify that 1 have read ton gree to non and stole that the s�o
above information qRd S n correct I agree to comply with all County r�
ordi nces State Iowa relating to budding electrical Issuance Fee
m nical )lumbing construction and hereby authorize Imewgotion fee }}ss
re senton f this County to enter upon the above Total Fee I V
Toned or inspection purposes
5 tore of Applicant or Ageni D-on SEE REVERSE FOR EXPLANATORY LANGUAGE