HomeMy Public PortalAbout5710 ROWLAND AVE_Swimming Pool__ 1 }
WORKERS'COMPENSATION DECLARATION, I �j
I lul
Y hereby affirm that I have cdCate of consent to self APPLICATION FOR COMBINATION! SIN'VMMING POOL PERMIT
unsure, or,a certificd7e Worr kers";,rmpens5tion Insurance,
or a certified co0y ther (S�jc.3800, Lab. C.) 76A20B
N,n $11Qompany ��LO"1•1 CE876(3/eat
Policy rr.L_ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING C
Certified copy is filed with the county building inspec- ADDRESS ,`J
tion department. BUILDINGI� o
Date-401—Applicant
ADDRESS �oWLhNO LOCALITY
,
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY `e, G ZIP q�'1$O CROSS ST.
COMPENSATION INSURANCE SIZE F ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one TEL.��/ USE ZONE [&Pi�_IIAL
hundred dollars($100)or less.) OWNER i K. G NO.zqp���D
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner ADDRESS! S. A,A. � DITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
PP CITY ZIP SCLASS NO.
t� CONST.
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER j NO.
Exemption, you should become subject to the Workers' ADDRESS VALUATION
Compensation provisions of the Labor Code, you-must forth- VALIDATION
with. comply with such provisions or this permit shall be TEL.
$
O,0
deemed revoked. CONTRACTOR `,S NO.ZBS-Z ( 14 V.
LICENSED CONTRACTORS DECLARATION LIC.
ADDRESS '2%ob T-LAsT unaS NO. S10'z
I hereby affirm that I am licensed under provisions of Chapter 9 LIC $
(commencing with Section 7000) of Division 3 of the Business CITY S b<<el CLASS C`s3
and Professions Code,and my license is in full force and effect. DESCRIPTION OF WORK
FINAL
License Number IGS IOZ Lic. Class C—S3 SWIMMING POOL DATE
o� SPA i �� O��oL! � a
Contractor Date `5 0 FINAL -2 6 9 a 7 A O
❑ SQ IZ FT. jL� BY # o o o o 2.1 a
I am exempt under Sec. SIZE `►�
B.&P.C. for this reasonELECTRICAL J o a 8 1'879
Date: � � I/vr0'0 0 84.79.
a.
Signature Steel &Conduit Bonding
g Conduits, Conductors, Equipment u
SINGLE FAMILY O 5,0 7`. 8 7 Z
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License ® 6 9 a 8 A
Law for the following reason (Section 7031.5, Business and P-Trap K
Professions Code): Gas System k # 3
0 0 0,0,0
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I,or my employees with wages as their '1 - 29550
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered o•o 2 9 5,5 0 5
for sale (Section 7044 B&P Code). Swimming Pool Heater WO
CONSTRUCTION LENDING AGENCY 0507-87
I hereby affirm that there is a construction lending agency for APP(ICAN.; TEL. l�•Z�OI
the performance of the work for which this permit is issued PRINT NO. ,
(Sec. 3097, Civ. C.). W4 5--_ -
Lender's Name ADDRESS S•• �)•A
Lender's Address P.C.Fee$ E 1 Permit Fee
I /1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County /�
ordinances and State laws relating to building, electrical, Issuance Fee `! t J e)
mechan' al and plumbing construction,and hereby authorize Investigation Fee r
represe a Ives this County to enter upon the above- Total Fee J , r
mentio d ert for inspection purpose . p
5 0 .
Signature of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE --