HomeMy Public PortalAbout10661 ROSEGLEN ST_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
Insuere or a cby rm that I ertlf cafe have orakeri Com'pe°;at�o n�:u'rancef APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
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Sec. La C. `/` 76A2DB
F11 (E-875(11/81)
Policy No. mpany COUNTY OF LOS.ANGELES 61JILDING AND SAFETY
F] Certified copy Is hereby furnished.
Certifled copy Is filed with the county bul Irupec- FOR APPLI TO FILL IN Aoo Eu
if d rt m nI. BUILNNG
/ ADDRESS LOCALITY
Dat e�v Appllcant +" E�
CERTIFICATE OF EXEMPTION FROM WORKERS' CFfY ZIP CRO55 ST.
COMPENSATION INSURANCEI SIZE-OF e 10,
ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
is
section need not be completed ff the permit Is for one USE ZONE MAP
hundred dollars($100)or leas.) OWNER 'y �f i Q N0.
I certify that In the performance of the work for which this J SPEClA1
permit Is Issued, I shall not employ any person In any manner ADDRESS ' �/ CONDITIONS
so as to become subject to the Workers'Compensation Laws. ISTRFCT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CLASS NO CONST.
Date Applicant ARCHITECT `, 7
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO' 7 a
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS 000 VALIDATION
with comply with such provislom or this permit shall be CONTRACTOR A $
deemed revoked.
LICENSED CONTRACTORS DECLARATION LIG
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. $
(commencing with Section 7000) of Division 3 of the Bwlneu CITY — >-
and Professlons Code,and m license Is In full force and I OF WORK
FN/11 ✓/ r ,
License Number Llc. ClassPFT
POOL DATE / �
/ r FINAL O
Contract `J Dat � ,Y �p"ii�l VW
❑ I am exempt under Sec. y
B.BP.C, for this reason ELECTRICAL Z
Date:
Signature Steel 8 Conduit Bonding
g Conduits, Conductors, Equipment
SINGLE FAMILY S 5 9 5 3 A
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's LicensePoo. #f To 0 0 o 2
Law for the following reason (Section 7031.5, Business and P-Trap
Profeulons Code): Gas System 2 ° ° 5 1. 6 0
❑ I, as owner of the property, will do the plumbing and Anti-Syphon 5 1.6 iS
electrical work. I,or my employees with wages as their o a o Q
sole compensatlon,ar a licensed contractor will do all MECHANICAL / Q 2—8 3
other work and the structure Is not intended or offered .
for sale (Section 7044 B&P Code). Swimming Pool Heater c 595 4 A
CONSTRUCTION LENDING AGENCY
I hdreby affirm that there Is a construction lending agency for APRICANTTEL. i} o o 1 o 0 0
the performance of the work for which thls,permlt Is Issued (PRINT) t , 2'° 1 8 �
(Sec. 3097, Clv. C.). G
Lender's Name ADDRESS .0 ° 8 2 0 0
/� � Q12-83
Lender's Ad P.G Fee$ 1p Permit Fee
I certify hat I havLthis application and state that the
above In onogree to comply with all Countyordinanc n Srelating to building, electrlcal, Of1a�°mocha al pinstruction, and here authorize Invefttgotlon F-ee repro ntatly ty to enter upon e a ve- Total F-eeo ction purposes
SI re of Applicant Ape t EEE REVERSE FOR EXPLANATORY LANGUAGE