HomeMy Public PortalAbout6008 ROWLAND AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have••,a certificate of consent to self ^
insure, or a certificate of Workers'Compensation Insurance, APPLICATION FDR COMBINATION SVOMMING POOL PERMIT
or a certified copy thIRreof(Sec. 3800, Lab. C.) 76A20B ,*,
i GE876(3/84)
Policy No. Company7. k 1� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
BUILDING
FOR APPLICANT TO FILL IN
F211c'ertified copy is filed with the county building inspec- ADDRESS 0000
tion department. BUILDING ��,[ �;_ F4-1::O+
4
ADDRESS t/(J YV�/`C!�/I/ LOCALITY
Date �� ApplicantP9 CI7-= IPG �l ZIP 17 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE SIZE O ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
hThis section need not be completed if the permit is for one / q� 114 TEL USE ZONE MAP
undred dollars($100)or less.) OWNER J !! 1A NO..f NO.
I certify that in the performance of the work for which thislJ�j�RW
/ �L SPECIAL
permit is issued, I shall not employ any person in any manner ADDRE D'o {`CJY� • A�P CONDITIONS
so as to become subject to the Workers'Compensation Laws. n DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY L � / / ZIP / J � CLASS NO. CONST.
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT:-If, after making this Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you.must forth- ADDRESS VALIDATION
with comply with such provisions or this permit shall be CONTRALTO TE $
deemed revoked. oML
LICENSED CONTRACTORS DECLARATION ADDRESb. IC
I hereby affirm that I am licensed under provisions of Chapter 9 LIC. $
(commencing with Section 7000) of Division 3 of the Business CITY �L CLASS
and Professions C de,and my license is in full force and effect. '
DESCRIPTION OF WORK FINAL _
License Number Lic. Clas� SWIMMING POOL 1 DATE y' ►• -
SPA L�
Contract r r Date I FINAL
❑ SO.FT. BY a
I am exempt under Sec. SIZE - O
B.&P.C. for this reason ELECTRICAL U
Date: O
Steel &Conduit BondingEU
1
Signature SINGLE FAMILY Conduits, Conductors, Equipment W
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 a
Professions Code): P-Trap i li'-:t.)"s
Gas System
I, as owner of the property, will do the plumbing and Anti-Syphon 33112: 208.t
electrical work. I,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered f;•fis a
for sale (Section 7044 B&P Code). Swimming Pool Heater ��-t°�
CONSTRUCTION LENDING AGENCY -!MR -- 'i,•
I hereby affirm that there is a construction lending agency for APPLICANT r `? T
the performance of the work for which this permit is issued (PRINTpbN
� �p � � j—��� _ -���`
(Sec. 3097, Civ. C.). , 7'�
Lender's Name TOTAL
1��� ��� s d �
ter` 66 . �,
ADDRES t {j�„UCK 941 �+
Lender's AddressP.C.Fee$ Q�/ Permit Fee t HANGS "j Il
(/ zv ls�
I certify that I have read this application and state that the /
above information is correct. I agree to comply with all County 2�0
ordinances and State laws relating to building, electrical, Issuance Fee
mechanical and plumbing construction,and hereby authorize Investigation Fee �j �, (/ i Ir�I�I [N i i fin'
representatives his County to enter upon the above- Total Fee f z t (e
t ed plop ray r inspection purposes. iO+Z li 1f j1-"11�',t
_Fa ure of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE