HomeMy Public PortalAbout5813 ROWLAND AVE_Swimming Pool__ WOK 'PFS'C I TI , ON �® n �j�q({ 5�
tierdi(j� cti'irm hat e r cerTCo nsent to self APPLICATION FOR COMBINATION SWIMMING POOL I1�EIlSll�ltl�ll
ins.ire, or a certificate orkers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.) 76A20B
A 7 CE876(3184)
Policy No. ompanyF .rluw..s�-- COUNTY OF LOS ANGELES BUILDING AND SAF TY
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING ,
CF-+ified copy is filed with the count building inspec- ADDRESS
i. n e rtment. BUILDING
ADDRESS I 2> ��W IQ(r� LOCALITY
Dare Applicant r NEAREST
C RTIFICATE OF EXEMPTION FROM WORKERS' CITY ` `t?, ZIP _`� CROSS ST.
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section noed not be completed If the pormit is for one TEL. G�r /`[c USE NE MAP
hundred dollars($100)or less.) OWNER E I S( r N�O f"�7 Ll � ' NO.
I certify that in the performance of the work for which this p SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS S
so as to become subject to the Workers'Compensation Laws. J DISTRICT STATISTICAL CLASS TYPE PROCESSE Y
CITY ( I ZIP �� J�� CONST.
Date Applicant ARCHITECT OR TEL. QJf CLASS N� r�
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. �J
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such � VALIDATION
p y provisions or this permit shall be TEL. y
deemed revoked. CONTRACTOR O. (f)�`•v�.Z $ I S Dao
LICENSED CONTRACTORS DECLARATIONL, •. _ LIC• �Ej'L
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �N�(r� NO. OJ $
(commencing with Section 7000) of Division 3 of the BusinessCITY CLASS
.
LIC. 7$Q.2 A
and Professions Code,and my license is in full force and effect.
1 bb DESCRIPTION OF WORK # a o a o L
1 OS 0� L�O-7 FINAL
License Number Lic. Class SWIMMING PO.O;L 'r DATE z— 0 09.594
SPA S 1 U PLAN Z?_Z_R J ® FI L
Confrocto� Date / 0 - 95946
Q
SQ.�. /,y �d
I am exempt under Sec. SIZE SSQ tt
09.04-87
6•
B.BP.C. for this reason ELECTRICAL G
Date:
Signature Steel &Conduit Bonding LL.J p
Conduits, Conductors, Equipment ��yt�r #6 7 8 0 0 0 IL 0 0 3 U)
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License0333.00
Law for the following reason (Section 7031.5, Business and P-Trap
Professions Code): Gas System a a 3 3 3,0 0 6
I, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. I,or my employees with wages as their 09,04-87
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
APPLICANT
the performance of the work for which this permit is issued
TEL. �f
(PRINT) O -�SJ"'1.�A01
(Sec. 3097, Civ. C.) c (�
Lender's Name �— ADDRESS 4
Lender's Address .�^ 3 a a s
P C.Fee$ LV/ Permit Fee
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
mechanical and pl construction,and hereby authorize Investigation Fee
represe atives thi ounfy to enter upon the above- Total Fee
m d prop r f spection purpose
Signa re of Applicant or Agent
'Die SEE REVERSE FOR EXPLANATORY LANGUAGE