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HomeMy Public PortalAbout5715 ROWLAND AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION hereby affirm that I have certificate of consent to self APPLICATION FOR COMBINATION SWIMMING POOL PERMIT insure, or a certificate of Workers'Compensation Insurance, or a cehified copy there9f(Sec. 3800, Lab. C.) 78A20B p lJ ' r4� r—tA f� CE878(3/84) Policy N Company COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. BUILDING Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS �r"�w VI_AAI/> tion department. BUILDING,57i ADDRESS ,,JJ �t ` LOCALITY Date I t lfJ Applica t% /•1 t —�T� NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CITY _ (id r ZIP �I(xJ CROSS OR Q COMPENSATION INSURANCE TRACT LOT SIZE OF LOT NO. MAPASSESBOOK X177 PAGEaO PARCEIde (This section need not be completed if the permit is For oneTEL. USE ZONE MAP hundred dollars($100)or less.) OWNER 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 57i.5 /�/Yl^z1�/ ��J�/ /� CONDITIONS so as to become subject to the Workers'Compensation Laws. CITY �/�f f//�� (�J zip � (1 DISTRICT STATISTICAL CLASS TY t PROCESSED BY Date Applicant ARCHITECT OR TEL. (/ CLASS NO. NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. �U ✓� �'�r Exemption, you should become subject to the Workers' ADDRESS VALUATION Compensation provisions of the Labor Code, you..must forth- I �� Jam)/� �_ VALIDATION with comply with such provisions or this permit shall be CONTRACTO L NO. $ Wv deemed revoked. Q��/� _' _ y� LICENSED CONTRACTORS DECLARATION gDDRESSX71c(� �. L(//� 1. 15 C/ 1 hereby affirm that I am licensed under provisions of Chapter 9 j $ (commencing with Section 7000)of Division 3 of the Business CIN1�1,Al ( CLAS Sj and Professions Code,and my license is in full force andeect. DESCRIPTION OF WORK FINAL, License Number vZ Lic. Clas� � SWIMMING POOL //r /y �/ © DATE :i ,��� �JTL!�` 6���Date �SU SPA �`��fJ 70 © FINAL' Contract SQ.FT. BY6301 &2r 4 ❑ I am exempt under Sec. SIZE B.&P.C. for this reason ELECTRICAL C Date: H Steel &Conduit Bonding L Signature Conduits, Conductors, Equipment X rL SINGLE FAMILY HOME OWNER-BUILDER DECLARATION PLUMBING ® Z 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 S stem y_ _ y I, as owner of the property, will do the plumbing and Anti-Syphon electrical work. I,or my employees with wages as their 4, sole compensation,or a licensed contractor will do all MECHANICAL other work and the structure is not intended or offered for sale (Section 7044 B&P Code). Swimming Pool Heater 0s~_, yz - CONSTRUCTION LENDING AGENCY '''`0- 3 iti:'• L- I hereby affirm that there is a construction lending agency for APPLICANT TEL ��— 11 TgEMS : the performance of the work for which this permit is issued rV � ' .L s P P (PRINT ( � .s o- (Sec. 3097, Civ. C.). , !i T j�_ r-11 a Lender's Name ADDRESS!10 /✓•/ f'1427 k.:: Lender's Address /' �`J Permit Fee P.C.Fee$ I certify that I have read this application and state that the - abotre information is correct. I agree to comply with.all County �,�� Issuance FeeE ordinances and State lows relatingto building, electrical, 4111!1_01 `�� ''+= g investigation Fee t� .vJIJ i �1..L ■•! mechanical and plumbing construction,and hereby authorize 9 / ��/ _ s representatives of this County to enter upon the above- Total Fee J t mentioned prop;rt or inspection purposes. Si a ure of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE