HomeMy Public PortalAbout9578 PENTLAND ST_Swimming Pool__ 5
JSATION DECLARATION
,e r�;cer0icq,e of tool eqt to �-if} �
®® ® �y �p� p(��a
au orkers',Compensation Insurance, �rA9 [i L�CAV®H F®R COMBWA y I®N S�F"�p�k'd`�] EG POOL PERMIT
or a.ceitified copy thereof (Sec. 3800, Lab. C.,) j6A?o8;1F pp
r CE676 3/84)
Policy � Company COUNTY OF LOS ANGELESj411-11LDIRIICs APdD SAFETY
Certified copy is hereby furnished.
Certified copy is
;iled with the county building inspec i FOR APPLICANT TO FILL IN ADIDRESS �V- 11yy\\
LDING
tion department. BUILDING C J v 4Y
`7 ADDRESS J ��ftJ Cali"N� LOCALITY �� fAl"
Date 6� /— Applicant NEAREST
CITY 11 � �� 1. ! ZIP 9f �� CROSS ST lE
CERTIFICATE OF EXEMPTION FROM WO KERSSIZE OF ASSESSOR ,1"
COMPENSATION INSURANCE TRACTL
LOT LOT NO, MAP BOOK AGE PARCEL
(This section need not be completed if the permit is for one /1 TEL. �7 USE ZONE MAP
hundred dollars ($100) or less.) OWNER �, 2V NO.7-8�"�355 NO..
I certify that in the performance of the work'for which this ISPECIAL
.
permit is issued, I shall not employ any person in any mannerADDRESS J. tQ o O CONDITIONS
so as to become subject to the Workers'Compensation Laws. I DISTRICT'- STATISTICAL CLASS TYPE PROCESS D BY
CITY ZIP CONST j
- '' ` CLASS NO. CONST
1
NOTICE TO APPLICANT:Date Applicant ARCHITECT OR TEL
NT: 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 VALIDATI• Pd
with comply with such provisions or this permit shall be TEL. 77 ` $
deemed revoked ACTOR NO.LgJ -z�w�
LICENSED CONTRACTORS DECLARATION CONTRACTOR 1iC
ADDRESS NO.I
I hereby affirm that i am licensed under provisions of Chapter 9 LIC $
(commencing with Section 7000) of Division 3 of the Business CITY er-_6 �•e- CLASS C -s 3
and Professions Code,and my license is in full force and effect DESCRIPTION OF WORK
FINALi � �2.a
License Number L V I�Z ' Lic. Class SWIMMING POOL K1J > DATE ft -
1 L/1 t _ /.I �'7 r�
.Contractor Ca L 6 1 Date SPA �'. FIN
A ... o o 0 3 4, I % v 0'..
SQ FT. eY 06.27. 86
am exempt under Sec.
B BP.C. for this reasonO
ELECTRICAL 1 P���2 �� j W
Date: 5
nature Steel & Conduit Bonding n 0..
Si
vl 0-
g Conduits, Conductors, Equipment z
SINGLE FAMILY
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
1; s owner of the property, will do the plumbing and . Anti-Syphon
`ctrical 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 r�
for.Isale (Section 7044B&P Code). Swimming PoolCE
Heater
CONSTRUCTION LENDING AGENCY >
hereby affirm that there is a construction lending agency for APPLICANT TEL ; 0
the performance of the work for which this permit is issued PRINT) f �p0ls X10
(Sec. 3097,.Civ. C.).
Lender's Name ADDRESS
Lender's Address P.C. Fee'$ Q 257.S-777'QC
k V �•� Pennitfee LOJ O'O -
I certify tliat l have read this application and state that the
above information is correct. I agree to comply with all County b, Sed
ordinance and State laws relating to building, electrical, Issuance Fe
mechani d plu i construction, and hereby authorize Investigation Fee
represen 1 es of this County to enter upon the above- ToraLFee SD
menti. d o r,inspection purposes. 7
in Applicant or Agent Date ISEE REVERSE FOR EXPLANATORY LANGUAGE