HomeMy Public PortalAbout5543 ROBINHOOD AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARAIAN C
affitm that I have a certificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
In or a certificate of Workers' Compensation Insurance,
r certlfled copy thereof (Sec. 3800, Lab. C.) 76A23B
CF-�875(11/81) .
Policy Company La" r COUNTY OF LOS ANGELES BUILDING AND SAFETY
F-1 Certified copy Is hereby furnished.
�erttfled copy Is filed wlt}t the county building Inspec- FOR APPLICANT TO FILL IN ADDRESS
�f
tion department. BUILD{NG
ADDRESS 1 l LOCALrry `f
Date Applicant T
CERTIFICATE OF EXEMKE
PTION FROM WORKERS' CCrY I ZIP / U AMAP
STSSOR
. _
COMPENSATION INSURANCE SIZE SSP BOO
TRACT LOT LOT NO. AP BOOK PAGE. PARCEL
VU section'need not be completed ff the permit Is for one TEL USE ZONE MAP n
hundred dollar (1100)or less.) OWNER NO. �J NO. C/
1 certify that In the performance of the work for which this U� SPECIAL
permit Is Issued, I shall not employ any person In any manner ADDRESS S CONDrrIONS
to as to become subject to the Workers'Compensation Laws. DISTR STATISTKIU C7AS5 TYPE PROCESSED BY
ARC ZIP U LASS NO. CONST.
Date ` Applicant ARC]IITECT TEL aENG4 `
NOTICE TO APPLICANT: If, after making this Certificate of d �'
ft
Iry
Exemption, you should become subject to the Workers' VAWAMN
Compensation provlslons of the Labor Code, you must forth- ADDRESS
VALIDATION
with comply with such provlsLons or this permit shall be
deemed revoked. GONTIRA�� S �'
LICENSED CONTRACTORS DECLARATION NO.NO
I p
I hereby affirm that I'am Ilcbrued under provisions of
of Chapter 9 uC ;
(commencing with Section 7000) of Division 3 of the Buslneas GTS, S-5-,,% GoL be-�� C1A55 c— }
and Profession Code,and my license ie In full force and effect. CL
DESCRIPTION Or-WORK HNAL O
License Number �bZ LIc. Claw S� SWLYMNG POOL DATI pool1 5 9 Q ? A u
r OL
Contractor 1� ��[S Date �A HNAL C� ° ° ° ° 2 1 O ,
FJI.am exempt under Sec. S Fr. BY �+ �_ 5.9 8 W
B,BP.0 for this reason ELECTRICAL 45g8� —
°I° °
.Date: I ,Q1 1 =8 3
SI mature Steel 8 Conduit Bonding �
9 Condults, Conductors, Equipment
SINGLE FAMILY
HOME OWNED-BUILDER DECLARATION PLUMBING ,
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and P-Trap
Professions Code): Gas tem _
EJ1, as owner of the property, will do the plumbing and Anti-Syphon 5 9 Q 3 A
electrical work. 1,or my employees with wages as their Z
sole compensatlon,or 4 licensed contractor will do all MECHANICAL # 0 0 0 ° o "
other work and the structure Is not intended or offered f
for.sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY ;' 0 1 6 4, 2,6
I hereby affirm that there Is a construction lending agency for
Ta-
the performance of the work for which this permit Is Issued �NT P Ymb Zg o ° 1 6 4, 2 6�
(Sec. 3097, Cv. C..).
v h ,�oL.�J I Q 1 1 -83
Lender's Name ADDRESS ��C.
Lenders Addreay`
P.C- Fees (��f L �+ P-r-rnit Fee
I certify that I have read this application and state that the -r /
above information Is correct. I agree to comply with all County C.l
ordinance! and State laws relating to building, electrical, Issuance Fee
mach a plumbing construction,and hereby outhorize Invesrlpatlon Fee LZN
re it of this County to enter upon the above? Total Fee evi, Zlo Z
m perty for Inspection purposes.
of Applicant or Agent SEE REVERSE FOR EXPLANATORY LANGUAGE