HomeMy Public PortalAbout6119 ROWLAND AVE_Swimming Pool__ WORKERS'COMPENSATION DECLARATION
I Fik4y affirmnthat I have a certificate of consent to self
in ,ire, or cih:;rfificafe of Workers'Compensation Insurance, APPLICATION FOR COMBINP,rTiON SWIMMING POOL PERP&IT
or a certtfied.�2py thereof(Sec. 3800, Lab. C.) i CE876(3/84)76A20B
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Policy�No. Company e.
1p COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished.
42
0 FOR APPLICANT TO FILL IN BUILDING //
Certified copy is filed with the county building inspec- ADDRESS
do de arfinent. BUILDING q /
Date �� I+ ADDRESS �� �= LOCALITY
Applicant I
CITY , ,,�� ZIP NEAREST
C...o(.� lx- � CROSS ST.
CERTIFICATE OF EXEM ION FROM WORKERS' SIZE O ASSESSOR
COMPENSATION INSURANCE TRACT LOT LOT NO. 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.) OWNER l NO. NO.
I certify that in the performance of the work for which thisSPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS ej CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CONST.
Date Applicant ARCHITECT OR TEL d CLASS NO."�
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER ( NO. ^�� dQ �:/� V Gtr ct—
,Exemption, you should become subject to the Workers' r VALUATION
Compensation provisions of the Labor Code, you-must forth- ADDRESS �YNjC � �jj �j
with comply with such provisions or this permit shall be TEL. {7 VALIDATION
deemed revoked. CONTRACTOR l (� /Z �S NO. $ � (�
LICENSED CONTRACTORS DECLARATION . LIC.
/
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. $
(commencing with Section 7000) of Division 3 ofLIC.
the Business
and Professions Code and my license is in full force and effect. CITY CLASS
I ��7 DESCRIPTION OF WORK
License Number L/ Lic. Cl a FINAL
/C i C� SWIMMING POOL (J DATE � � � a
7
Contracto , C( � IZ Date ` ` SPA FINAL y V
SQ.,FT. `^T] BY
I am exempt under Sec.• SIZE
B.&P.C. for this reason ELECTRICAL ���
Date: �Q 78 W
Signature Steel &Conduit Bonding in
Conduits, Conductors, Equipment t37
SINGLE FAMILY _Z
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License Boo
Law for the following reason (Section 7031.5, Business and P-Trap
Professions Code): Gas System y-
I, as owner of the property, will do the plumbing and Anti-Syphon =� -''' '
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
for sale (Section 7044 B&P Code). I Swimming Pool Heater 3307 :85
_.�
CONSTRUCTION LENDING AGENCY •
I hereby affirm that there is a construction lending agency for / +�_ i_;';
APPLICANT TEL.!/%( .P"
the performance of the work for which this permit is issued PRINT --.;�_.-a Vis_
NO 11.1> _ 5
',(Sec. 3097, Civ. C.). '9' am,,,,,,, m, :,,F:;f
,Lender's Name ADDRESS •=tC x "d
Lender's Address /17�/y� H 1=tt I°?=
P.C.Fee$ / ' ,/ Permit Fee
I certify that I have read this application and state that the I
'above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee - J 011I i(- 1U,_�1 j
'mechanical and plumbingconstruction,and herebyauthorize Investigation Fee , -;
representatives of this County to enter upon the above- Total Fee l� / - I`'1 L t
!:/�fi�anedperty fo�inse n purposes.
, ` 2
ignature of AIlicaror Agent lbate SEE REVERSE FOR EXPLANATORY LANGUAGE