HomeMy Public PortalAbout6126 ROWLAND AVE_Swimming Pool__ comr-NSATION DECLARATION p� '1 q�
su -, '.a c that I have r certificate of consent to self APPLICATION FOR COMBINATION S�i111 ANNC POOL PERMIT
insu•a, or v c:•rtificate of Workr•;s' Compensation Insurance,
or asc tit;fie copy thorr:nf (Suc 3800 lab C 1 76A.Z)B
Polic'y`N r � ompany F"G� ���ti-� CE8 , •'•e4 COUNTY OF LOS ANGELES
BUILDING AND SAFETY
F1Certified copy iq,,,,-.•by t%rnishod
FOR APPLICANT TO FILL IN BUILDING •7
���rtified copy is filed with the count �jgnspec- ADDRESS sL
tion department. BUILDIN
ADD —t w L_ 1� LOCALITY bf
Date 2-- Applicant _ Q
CERTIFICATE OF EXEMPTION FROM WORKERS' CITY ( r ZIP \ ( Q fro CROSS NEAREST
COMPENSATION INSURANCE SIZE OF ASSESSOR
TRACT LOT LOT NO MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one ^t TEL. USE��AOOONE [SPECIAL
P
hundred dollars($100)or less.) OWNER �-� a 6C; 6 g NO.
1 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 NDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY ZIP CONST
Date Applicant ARCHITECT OR TEL. SD CLASS NO
NOTICE TO APPLICANT- If, after making this Certificate of ENGINEER NO. 3
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 –j- TEL
p y p p CONTRACTOR C60 00�3 1✓ NO Z gS�2 $ 00O
deemed revoked.
LICENSED CONTRACTORS DECLARATIONLIC•
ADDRESS 99M S v�7G.S NO. r�S OZ
1 hereby affirm that I am licensed under provisions of Chapter 9 c LIC $
(commencing with Section 7000)of Division 3 of the Business CITY J�� �a 1 e CLASS C —'—>3
and Professions Code,and my license is in full force and effect DESCRIPTION OF WORK FINAl7, n
License Number 1 O S�Z Lic. Class L _S 3 SWIMMING POOL pZ__14 ® 11, 1 0, 7 q
❑Contracto 4&19t, SPA S �
FIN a a a a
Date O
SQ FT BY U
I am exempt under Sec. SIZE 100906
�
B 8P C. for this reason ELECTRICAL a o o C 0 <6 0
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i
Date: „ ,- W
I if 2 5—8
Signature Steel 8 Conduit Bonding ® U)
Conduits, Conductors, Equipment
SINGLE FAMILY z
HOME OWNER-BUILDER DECLARATION PLUMBING
I hereby affirm that I am exempt from the Contractor's License
41 O,S.s,,G
Law for the following reason (Section 7031.5, Business and P_Trap
Professions Code): Gas System r; o o rs o o S
1, as owner of the property, will do the plumbing and Anti-Syphon
electrical work. 1,or my employees with wages as their i . 31 A. �6
sole compensation,or a licensed contractor will do all MECHANICAL l
other work and the structure is not intended or offered r o o 51 4,L 6
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 r
TEL
the performance of the work for which this permit is issued (PRINT) C_ �aOIS NO.
(Sec 3097, Civ. C )
Lender's Name Vn IC ru ADDRESS
Lender's Address 2 O b
PC Fee$ at J 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 jaws relating to building, electrical. Issuance Fee [ 3 i
mechanical d plumbing construction, and hereby authorize Investigation Fee
representor es this County to enter upon the above Total Fee24
mentione p P r for inspection purposes.
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Signatur n pplicant or Agent Dote SEE REVERSE FOR EXPLANATORY LANGUAGE