The URL can be used to link to this page

Home My Public Portal About6202 ROSEMEAD BLVD_Swimming Pool__ WQRKERS'COMPENSATION DECLARATION Hereby affirm ca I have certificate of consent to self APPLICATION FOR COMBINATION SWIAWI NG POOL PERMIT insure, ora certificate of Workers'Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab. C.) 7BA20B CE876(3/84) Policy ] Company_�� Is� COUNTY OF LOS ANGELES "' UILDING AND SAFETY Certified copy is hereby furnished. BUILDING Certified copy is filed with the c nt,Ti building in - FOR APPLICANT TO FILL IN ADDRESS DateI,an de`partm nt. BUILDING -aC) > � 1._� i ADDRESS ✓ (fT-�#�i Y✓tivt LOCALITY / Cr(M CrI `r Applican A NEAREST CERTIFICATE OF EXEMPT`IG�ROM WORKERS' i CITY2-210A, Glu ZIP �� /(} CROSS ST. COMPENSATION INSURANCE T CT A LOT LOT NO.IZE OF MAP BOOK PAGE PARCEL®� (This section need not be completed If the permit is for one TEL. �� USE ZONE MAP hundred dollars($100)or less.) RLa�--�� _Z 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 '20 7 056ke78$10 9609; CONDITIONS so as to become subject to the Workers'Compensation Laws. / DISTRICT STATISTICAL CLASS TYPE PROCESSED BY CITY(P+ Z G-f ZIP �7 rQ CONST. Date Applicant I ARCHITECT EL. CLASS NO. NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER ov !( 05'2 �/ Exemption, you should become subject to the Workers' VALUATION Compensation provisions of the Labor Code, you.must forth- ADDRESS(_ S ,�,,rr f1 / �7♦•7 VALIDATION with comply with such provisions or this permit shall be CONTRACTOR �l«�i % aUl�C NO.�L! - �� $ �7 000 deemed revoked. �ry LICENSED CONTRACTORS DECLARATION �� V� NO. ADDRESS � ' I hereby affirm that I am licensed under provisions of Chapter 9S (commencing with Section 7000)of Division 3 of the Business C(a 01'6 LIC: and Professions Code,and m license is in full force and effect. i CITY CLASS �`� _ Y DESCRIPTION OF WORK Class '/ � I ' FINAL 9 /9 ► License Number Lic. -J -� I SWIMMING POOL +��C�^�� © DATE Contractaf C U�.tt Date 31-11-- 76 I SPA #q��p 0 77 ❑ BY A/Y a I am exempt under Sec. I SIZE ,� / ti..d O B.&P.C. for this reason ELECTRICAL U Date: O Steel &Conduit Bonding ~ Signature ( Conduits, Conductors, Equipment O W SINGLE FAMILY EL HOME OWNER-BUILDER DECLARATION I PLUMBING ® 23 Cn Z I hereby affirm that I am exempt from the Contractor's License f Law for the following reason (Section 7031.5, Business and P-Trap ACCT a9 Professions Code): 0 Gas System I, as owner of the property, will do the plumbing and Anti-Syphon 3303 161■89 electrical work. i,or my employees with wages as their i sole compensation,or a licensed contractor will do all I MECHANICAL other work and the structure is not intended or offered I Al•4T■V for sale (Section 7044 B&P Code). Swimming Pool Heater Q CONSTRUCTION LENDING AGENCY3303 575■08 I hereby affirm that there is o construction lending agency for APPLICANT .. ' r' TEL.(" ! 2 ITEMS the performance of the work for which this permit is issued (PRINT) /j j" NO.�V&- O1 / (Sec. 3097, Civ. C.). / �7 � TOTAL 736.97 x'36-0 97 Lender's Name ADDRESS JtQ[' '/�G.�/f /1+��, �fj�`�� CHECK !36.97 Lender's Address �/ 7 74� CHANGE ■00 P.C.Fee$ Permit Fee I certify that I have read this application and state that the above information is correct. I agree to comply with all County 7 ordinances and State laws relating to building, electrical, Issuance Fee 0000-0001 3J11J96 mechanical an umbing construction,and hereby authorize Investigation Fee representat• s/of his Count to enter upon the above- Total Fee �� r mentio .pr6pe�f for ins ecfto ur oses.p �� 1 F('��?■0• Si nature of A p) rrf—or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE